Lunate biomechanics: application to Kienböck's disease and its treatment.

Kienböck's disease was initially considered as lunate osteomalacia due to lesions of its nutrient arteries during carpal ligament tears. It has also been suggested following primary fractures, or because of repeated microtrauma. It is only in the past 20 or 30 years that it has appeared as aseptic necrosis. Based on Hultén's hypothesis that a negative radioulnar index was the cause of Kienböck's disease, equalization osteotomies (shortening of the radius or lengthening of the ulna) were developed. The observation of Kienböck's disease in subjects with a positive index and the risk of ulnar abutment after osteotomy led to the introduction of new osteotomies to get around these difficulties, still in the hope of treating the cause of Kienböck's disease. While it has been confirmed that a negative radioulnar index promotes lunate fracture, it clearly does not induce the pathology in the form of necrosis. In this scenario, perilunar osteotomies produce durable decompression, limiting the risk of lunate fracture in case of necrosis by removing the compressive constraints. After comparing the different osteotomies used to treat Kienböck's disease, it seems that the Camembert osteotomy for radius shortening, combined with selective shortening of the ulnar head as described by Sennwald, decompresses the lunate maximally, and protects it long enough for potential natural revascularization to occur.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome.

Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.

COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Arthroscopic-assisted 6U approach for foveal reattachment of triangular fibrocartilage complex with an anchor: Clinical and radiographic outcomes at 4 years' mean follow-up.

The main objective of this study was to evaluate the long-term clinical and radiological outcomes of arthroscopic-assisted foveal repair of proximal triangular fibrocartilage complex (TFCC) tears with an anchor. The secondary objective was to look for ligament damage associated with TFCC tears. Twenty-four patients who underwent foveal repair of the TFCC were evaluated retrospectively: 16 stage 2 and 8 stage 3 in the Atzei-EWAS classification. The TFCC was repaired with an anchor using an expanded 6U approach. Systematic testing of intrinsic and extrinsic ligaments was performed. The assessment criteria were pain on a visual analog scale (VAS), wrist joint range of motion, grip strength and pronation-supination strength, and the QuickDASH and PRWE outcome scores. X-rays were also taken to assess anchor position and to look for distal radioulnar (DRU) joint damage. The average follow-up was 44 months. After the surgical repair, pain was reduced (7.36±1.3 preoperatively vs. 0.69±1.3 postoperatively; P<0.001), the QuickDASH score improved (52.1±16 vs. 21.7±7; P<0.001), the PRWE score improved (83.7±35 vs. 9.3±12; P<0.001) as did strength (35 vs. 43kg; P<0.001). The DRU joint stability was also significantly improved. The time away from work was 2.6 months. During the arthroscopy exploration, 25% of patients had an ulnotriquetral ligament lesion and 8% had an ulnolunar ligament lesion in combination with their TFCC tear. Fifteen anchors were positioned in the anatomical fovea (62%). No DRU joint damage was noted. Six patients had neurapraxia of the dorsal branch of the ulnar nerve, although it recovered spontaneously. One patient still had hypoesthesia of the ulnar side of the fifth finger at 48 months. Arthroscopic-assisted foveal repair of the TFCC yields good results in terms of pain, strength and DRU joint stability. In one-quarter of cases, TFCC foveal tears are associated with lesions of the ulnotriquetral ligament. There is no long-term degeneration of the DRU joint.

Dorsal scapholunate stabilization using Viegas' capsulodesis: 25 cases with 26 months-follow-up.

Intercarpal instability is often secondary to a scapholunate interosseous (SLIO) ligament lesion. Its reconstruction is thus essential. Classical capsulodesis techniques fix the scaphoid in extension and do not reproduce the physiologic ligamentous isometry of the wrist. The authors use the technique of Viegas, which seems to respect this isometry: the dorsal intercarpal ligament is re-inserted dorsally to reattach the capsule on the dorsal SLIO and to reinforce it. Between 2006 and 2010, 25 wrists were operated on in 12 men and 12 women of mean age 38 years. All patients presented with pain often associated with loss of power, decreased mobility or a debilitating click. The mean follow-up was 26 months. Postoperative and preoperative data were compared. Flexion/extension range increased by 2.6°, radioulnar deviation increased by 21.1°. Grip strength increased by 8.7 kgf. Pain decreased by 3 points on the VAS and the PRWE improved by 59 points. We observed four CRPS, one EPL lesion and one case of superficial track pin infection. We got eleven excellent results, nine good, two moderate and three bad, two of which were re-operated. Viegas' capsulodesis does not present major technical difficulty. The results show no stiffness in flexion/extension. There was evident improvement in radioulnar deviation, grip strength, pain and PRWE scores. This technique provides effective treatment for a difficult or irreparable lesion of the SLIO ligament, without fixed carpal instability corresponding to Geissler arthroscopic stages 2 to 4 and Garcia-Elias stages 3 and 4. The capsulodesis produces an effective stabilization without stiffness. Precautions should be undertaken to avoid CRPS and pin complications.

Arthroscopic criteria for dating wrist sprains.

OBJECTIVES: Dating wrist sprains has therapeutic and medicolegal importance. The authors propose a study validating three arthroscopic criteria to date the trauma. METHODS: The authors analyzed statistically one hundred arthroscopies performed between 1999 and 2008 after wrist sprains. They suggest three criteria to date the injury. They are: turbidity of synovial fluid (assessed T0 to T4), hemorrhagic infiltration of the synovium (evaluated S0 to S2), and the aspect of the articular cartilage (assessed C0 to C4). RESULTS: The importance of turbidity is significant with P<0.001. The importance of synovitis is significant with P<0.001. The extent of cartilage degradation is significant with P<0.01. These three criteria have also a very significant predictability. The authors distinguish four posttraumatic periods: the immediate period, less than 2 weeks, corresponding to T3/T4, S2, C0; the acute period from 2 to 6 weeks, corresponding to T1/T2, S1, C1/C2; the subacute period from 6 weeks to 6 months, corresponding to T0, S1, C3; the chronic period beyond 6 months, corresponding to T0, S0, C4. The association T2/T4, S2, C4 is clearly an acute injury with a previous pathologic situation. CONCLUSIONS: The arthroscopic criteria for dating a wrist sprain are simple to estimate. They are used to define the immediate, acute, subacute or chronic posttraumatic periods, and a previous pathologic situation. The choice of surgical indication is facilitated and an objective estimation of the length of lesion is useful in the forensic setting.

MR imaging of normal extrinsic wrist ligaments using thin slices with clinical and surgical correlation.

Eighty-nine MR examinations of the wrist were retrospectively analyzed. MRI results were compared with clinical findings and/or arthroscopy. Thin proton density and T2 weighted sequences and 3D DESS weighted sequences were applied on a 1.5T scanner. On the palmar side three radiocarpal ligaments are recognized including the radioscaphocapitate, radiolunotriquetral, radioscapholunate, and midcarpal triquetroscaphoidal ligaments. Ulnocarpal ligaments include the ulnolunate ligament and the ulnotriquetral ligament. On the dorsal side three ligaments are recognized: the dorsal radiolunotriquetral, and the midcarpal triquetroscaphoidal and triquetro-trapezoido-trapezial. The collateral ligaments include the radial and ulnar collateral ligament. MR is a valuable technique in the assessment of the extrinsic and midcarpal ligaments. Depiction of the extrinsic ligaments can best be accomplished with coronal 3D DESS sequences and sagittal and transverse proton density and T2 weighted sequences with thin slices.

Changes in grip strength in a randomized study of carpal tunnel release by three different techniques.

Carpal tunnel release is frequently followed by weak grasp but recently, endoscopy has been claimed to avoid this pitfall. 277 patients representing 303 CT were enrolled in a prospective randomized study to assess changes in grasp after classical open CTR (Group I - 77 cases), ligamentoplasty (Group II - 133 cases) and an Agee endoscopic CTR (Group III - 99 cases). Grasp was measured pre-operatively and post-operatively every month for six months to analyse strength recovery according to technique, dominance, sex, motor conduction velocity, job, and leisure activity.There were no complications in the series except one RSD and six open conversions in the Agee group due to technical problems.Pre-operative CT was accompanied by an average loss of strength of 18%. In the postoperative period, the contralateral side had an increase in strength from 2% to 12.5%. These data plus the frequent bilaterality of CT explained the bias of any post-operative study without pre-operative measurement.Strength recovered faster and better in Group II and III. At three months, the percentage of patients having recovered was 38% in Group I, 54% in Group II, 58% in Group III. An explanation of similarity in the last two groups could be found in the modification of Agee procedure preserving an intermediate fascia, avoiding full separation of the two edges of the ligament, as in the ligamentoplasty.

[A comparative study of metacarpal resection and translocation after amputation of the middle finger]. / Etude comparative des résections métacarpiennes et des translocations après amputations des doigts médians.

The authors studied 43 patients having sustained an amputation of one middle finger treated either by simple ray resection or translocation. The index-middle translocation was followed by more minor postoperative complications compared to all other techniques. A global score, taking into account daily activities, cosmetic result lack of mobility, residual pain, decreased strength, time off work, and return to work gave 131 points for simple third ray resection compare to index middle translocation (-252 points). Surprisingly, reduction of hand span on X ray study was minimal but strength was not correlated and translocation gave better strength, and therefore appears to be more appropriate for manual workers. For ring amputation, the score was definitely better for Leviet translocation with intracarpal osteotomy (143 points versus -36 for simple ray resection). However, the only drawback is more frequent (but minor) residual pain.

[Comparative study of various treatment methods of mucoid cysts of the fingers]. / Etude comparative de différentes méthodes de traitement des kystes mucoïdes des doigts.

100 mucocysts were reviewed in 93 patients. Surgical removal was done in 66 cases, associated with an osteophytectomy in 38 cases (57 p. cent). Among the 5 recurrence observed (7.6 p. cent), 3 occurred after simple excision, 2 occurred after associated osteophytectomy.

[Correction of posttraumatic disorders of the distal radio-ulnar joint with the Sauvé-Kapandji surgical procedure]. / Correction des désordres post-traumatiques de l'articulation radio-ulnaire distale par intervention de Sauvé-Kapandji.

The Sauve-Kapandji procedure was performed on 21 patients with posttraumatic lesions between May of 1985 and May of 1991; average clinical and radiological follow-up was 3.4 years. Causal mechanisms were as follows: 12 cases were sequelae of fractures of the distal extremity of the radius; 5 cases were sequelae of fractures of the diaphyses of the two forearm bones and/or of the head of the radius; 2 cases of instability of the distal radio-ulnar joint; 2 cases of posttraumatic isolated arthritis of the distal radio-ulnar joint. Subjective evaluation by the patients of the results of surgery was as follows: 8 excellent, 6 good, 2 satisfactory and 5 poor. The most consistent improvement was a gain of mobility in pronation and supination which averaged 87 per cent of that of the healthy contralateral side. Nine patients were free of pain, 6 experienced some pain only during effort, and 6 still suffered constant pain. Grip strength was the factor that changed the most: it averaged 55 per cent of that of the healthy contralateral side. Indications for the Sauve-Kapandji procedure and its results in posttraumatic lesions are discussed. This procedure is compared to other techniques used to correct posttraumatic disorders of the distal radio-ulnar joint.

[Comparison of treatment techniques of rhizarthrosis of the thumb. Apropos of a series of 98 cases]. / Comparaison des techniques de traitement de la rhizarthrose du pouce. A propos d'une série de 98 cas.

We compared 3 methods of treatment of trapezometacarpal arthritis: partial trapezectomy with Ashworth Blatt interposition and total trapezectomy with either Swanson spacer or anchovy procedure. Out of a series of 85 patients (98 operations), 52 (62 operations) were reviewed by an independent observer after a mean follow-up of 5 years. Silicone spacers were frequently complicated by subluxation, fragmentation and silicone synovitis. All procedures were effective on pain and mobility. Best results on strength were observed after trapezectomy with anchovy interposition and ligamentoplasty.

[Carpal tunnel syndrome. Can it still be a controversial topic?]. / Le canal carpien. Peut-il être encore sujet de controverse?

The authors studied two aspects of the carpal tunnel syndrome. As far as the diagnosis is concerned, clinical signs and provocative manoeuvres compared to the accepted standard of electrophysiological studies proved to be insufficient to settle a surgical indication in 85 carpal tunnel syndromes. When surgery is needed, post-operative course is frequently bothered by pillar pain and decreased strength postponing return to manual activities. The authors performed a prospective randomized study of 3 techniques in 251 carpal tunnel releases: classical technique, Agee endoscopic technique and anterior ligamentoplasty. Strength was only improved by the last technique. The only advantage for the endoscopic technique was greater post-operative comfort.

[The Herbert screw in the treatment of fractures and pseudarthrosis of the carpal scaphoid. Review of 25 cases]. / Utilisation de la vis de Herbert dans le traitement des fractures et pseudarthroses du scaphoïde carpien. Revue de 25 cas.

The Authors have reviewed the charts of 25 patients with scaphoid lesions treated with the Herbert screw and this study reports their personal experience. Between September 1983 and December 1986, 4 fresh fractures, 5 delayed unions and 16 pseudarthrosis were treated by means of this osteosynthesis procedure. The mean follow-up was 22 months. Bony union occurred in 21 patients. The series contains 2 failures defined as an absence of bony union after a post-operative delay of more than 6 months. There were 2 other cases considered as doubtful unions on X-rays. Wrist function, nevertheless, was restored in 23 patients. Plaster immobilization did not appear to be essential for every case. The short leave of absence, averaging 2 months only, is also in favour of this technique.