Effect of pronator teres muscle botulinum neurotoxin type-A injection on proximal median nerve entrapment.

PURPOSE: We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE). METHODS: Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology. RESULTS: None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores. CONCLUSION: The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE. LEVEL OF EVIDENCE: Level IV.

Plexiform neurofibroma (Hamartoma) of the median nerve: A two-case report.

Plexiform neurofibroma is a benign peripheral nerve-sheath tumor, rarely involving major nerves of the extremities. In the literature, there are no clear treatment strategies for plexiform neurofibroma of major peripheral nerves. Our experience encountered two patients with plexiform neurofibroma of the median nerve, presenting with a palmar mass and symptoms of carpal tunnel compression. Preoperatively, plexiform neurofibroma was diagnosed on MRI and clinical examination. Both patients also experienced significant neurological deterioration, with finger numbness and increased nerve/tumor size. Potential malignant transformation was also considered. For these reasons, resection of the involved area of the nerve and repair were indicated. In both patients, intraoperative pathological diagnosis was plexiform neurofibroma. The 45-year-old male patient refused further surgery after carpal tunnel release, which was performed under axillary block. One year postoperatively, nerve compression symptoms decreased moderately. In the other patient, a 7-year-old boy, a significantly enlarged area of the median nerve was resected, and neurorrhaphy was performed. One year postoperatively, median nerve motor-sensory functions recovered completely. Four years postoperatively, no enlargement of the residual tumor was observed.

Pinch strength analyses in lacertus syndrome.

PURPOSE: Lacertus syndrome is defined as proximal median nerve entrapment at the lacertus fibrosus. We aimed to analyze change in pinch strengths in patients who underwent median nerve release at the lacertus fibrosus under WALANT (wide-awake local anesthesia, no tourniquet). METHODS: Pinch strength was measured with a pinch gauge. Subjective DASH score and pain, numbness in the operated extremity and satisfaction on visual analog scales were analyzed before and 6 weeks after surgery. RESULTS: There were 32 patients. Median nerve release under the lacertus fibrosus elicited statistically significant increases in tip-to-tip, lateral and tripod pinch strength at postoperative week 6. Improvements in DASH score, pain and paresthesia were also statistically significant. CONCLUSIONS: For lacertus syndrome treatment, mini-incision release of the lacertus fibrosus under WALANT was satisfactory and increased pinch strength significatively. LEVEL OF EVIDENCE: Therapeutic, Level IV - Case series.

Radius palmar plate removal without carpal tunnel release: Correlation between plate position and median nerve symptoms.

We aimed to report the clinical results of volar plate removal without carpal tunnel release in patients with late-onset median neuropathy and to evaluate the relationship between plate position and median nerve symptoms. Part I. Twelve consecutive patients with late-onset median neuropathy treated with volar plate removal without carpal tunnel release were enrolled for analysis. Pre- and post-operative Tinel sign, Phalen and Ten test, subjective rating of tingling sensation, Mayo wrist score and Disabilities of the Arm, Shoulder and Hand (DASH) score were collected. Part II. 232 consecutive patients underwent volar plating for distal radius fracture. The relationships between median nerve symptoms and volar plate prominence on the Soong classification, fracture classification, gender and age were investigated. All cases except one showed complete symptom resolution at final follow-up, with negative Tinel sign and Ten test score of 10/10. Tingling was rated 0 at final follow-up. Mean Mayo wrist and DASH scores improved to 86.7 and 23.1, respectively. The incidence of the median nerve symptoms in our cohort was 5.6%. Even though the odds ratio in Soong grade 2 was 4.0957 (95% CI, 0.93-16.9) compared to the combination of grades 0 and 1, no statistically significant relationship was found between the median nerve symptoms and volar plate prominence (p > 0.05). Plate removal without carpal tunnel release adequately relieved symptoms of late-onset median neuropathy after volar plating in patients with distal radius fracture. LEVEL OF EVIDENCE: IV; Therapeutic.

Is there a need for postoperative monitoring after open carpal tunnel release under WALANT?

Open carpal tunnel release (OCTR) under wide-awake local anesthesia with no tourniquet (WALANT) is a common outpatient procedure in hand surgery worldwide. In our clinic, WALANT has replaced intravenous regional anesthesia with a tourniquet (IVRA, or 'Bier block') as standard practice in OCTR. We therefore wondered what the optimal postoperative setting after OCTR under WALANT is. In this study, we compared patient satisfaction in two postoperative settings: immediate discharge (ID) after the operation, or short postoperative monitoring (PM) period in the outpatient clinic. Our hypothesis was that older patients would prefer a brief postoperative surveillance. We retrospectively analyzed patient satisfaction with the two settings using an adjusted questionnaire based on the standard Swiss grading system. We also assessed postoperative pain, satisfaction with the perioperative preparations and the reasons for unscheduled postoperative consultations, as secondary outcomes. One hundred and nine patients (ID, n = 63; PM, n = 46) were included in this single-center retrospective observational study. Patients were highly satisfied with both postoperative settings (Mean: ID 5.1/6; PM 5.5/6; p = 0.07). Even patients aged ≥80 years reported extremely high satisfaction with both settings (ID 5.6/6; PM 6.0/6; p = 0.08). Fifteen patients (ID, n = 11 [17.5%]; PM, n = 4 [8.7%], p = 0.72) unexpectedly consulted a doctor after surgery. OCTR under WALANT as an outpatient procedure with immediate discharge was associated with high patient satisfaction. However, detailed postoperative monitoring could contribute to the patient's well-being and education on how to cope with the postoperative course, and help with any questions.

Carpal tunnel syndrome: Does preoperative disease severity influence the outcome of mini-open surgery?

In the practice of carpal tunnel surgery, open decompression of the median nerve in carpal tunnel syndrome (CTS) is recognized as the therapeutic priority. However, the speed and completeness of postoperative recovery of sensitivity and function depend on the initial clinical manifestations of the disease and the severity of the electrophysiological disorder. The aim of this study was to investigate the influence of preoperative clinical and electrophysiological factors on the outcome of surgical treatment of patients with CTS of varying severity. One-hundred and eighty-nine open decompressions of the median nerve via a mini-open incision were performed in 161 patients with idiopathic CTS. Clinical observations were classified in 5 groups, according to severity. Treatment results were evaluated per group at 6 weeks and 3, 6 and 12 months after surgery. In all cases, there was improvement and positive dynamics according to clinical and electroneuromyographic data. Open decompression of the median nerve via mini-open incision can achieve significant clinical and functional improvement in the majority of patients with CTS. However, the most favorable results were mainly seen in patients with initial severity classified in the first, second and third (lower severity) groups.

[Compressive false aneurysm of the brachial artery in a hemodialysis patient: Always superficialize the basilic vein of the arm!] / Faux anévrisme compressif de l'artère brachiale chez un hémodialysé : toujours superficialiser la veine basilique du bras !

The creation and preservation of vascular accesses, in patients with end-stage renal failure, remains a challenge for nephrologists and vascular surgeons. Native fistula is the best vascular access, humeral-basilic fistula is a precious access in patients who have exhausted their venous capital in the forearm and in whom the cephalic vein of the arm is small or damaged. Given its deep location, any puncture of this vein is prohibited before its superficialization, even if it is of good caliber, because it can have dramatic consequences, in particular the loss of the limb or even death. We report the case of a patient undergoing hemodialysis for seven years with a non-superficialized humeral-basilic fistula, admitted for an iatrogenic false aneurysm of the brachial artery following a puncture for dialysis, with compression of the median nerve, treated surgically.

French trends in carpal tunnel surgery: An online survey of members of the French Society for Surgery of the Hand.

Several surgical and anesthesia techniques are used in carpal tunnel surgery. The practices of members of the American Society for Surgery of the Hand and the Canadian Society of Plastic Surgery were recently published and compared. Because of the great difference in these practices, we investigated the practices of the members of the French Society for Surgery of the Hand and how they would change. An online survey including 14 systematic and 12 conditional questions was sent by email to all 685 surgeons who were members of the French Society for Surgery of the Hand in July 2019. Data were analyzed using descriptive statistics. The survey was completed by 129 members (19%). The open approach was used by 56% of the surgeons (8% by traditional open technique, 48% by minimally invasive open technique), endoscopic techniques by 40% and ultrasound-guided techniques by 4%. Most surgeons used regional anesthesia (69%) or local anesthesia (25%). Half of the surgeons (50%) would consider changing their surgical technique. Sixty-one percent were interested in ultrasound-guided techniques and 34% in endoscopic techniques. Almost half the surgeons (48%) would consider changing their anesthesia technique and 97% were interested in local anesthesia. Our study showed that the open approach and regional anesthesia were the most frequently used techniques but that an increase in endoscopic and ultrasound-guided techniques as well as local anesthesia techniques was likely. LEVEL OF EVIDENCE: Economic and decision analysis V.

Bilateral flexor digitorum superficialis brevis of the little finger: a rare cause of carpal tunnel syndrome.

An anatomical variant of flexor digitorum superficialis brevis is an uncommon condition that may be a pitfall in diagnosing carpal tunnel syndrome, involving palpable mass and even characteristic symptoms. We present an unusual case of bilateral symptomatic carpal tunnel syndrome related to the presence of a flexor digitorum superficialis brevis muscle of the little finger, and a critical review of the literature.

Intraneural perineurioma of the median nerve at the elbow: A clinical case.

A 31-year-old female patient presented with swelling on the anteromedial aspect of her right elbow with a sensory deficit in the median nerve territory. Biopsies led to the diagnosis of intraneural perineurioma (INP). Surgical excision was performed and followed by an intercalary graft. INP is a rare benign tumor of the peripheral nerves characterized by a multiplication of perineural cells invading the endoneurium. This lesion is often unknown, under-diagnosed, and its treatment is poorly defined. Few cases have been described in the literature; the majority involve the median nerve at the wrist and no references have been found about its localization to the median nerve at the elbow.

Heterotopic ossification on the volar surface of the distal radius in a child with fibrodysplasia ossificans progressiva: challenges in surgical excision of a rare condition.

Fibrodysplasia ossificans progressiva (FOP) is one of the genetic and developmental forms of heterotopic ossification. We report a case of FOP on the volar surface of the distal radius, located close to the median nerve and radial artery with neurologic symptoms secondary to median nerve entrapment. The patient underwent surgical excision of the heterotopic lesion followed by radiation therapy. He had no signs of recurrence with more than 1 year of follow-up. Careful microsurgical dissection of the heterotopic mass must be performed to prevent the formation of new painful lesions and iatrogenic neurovascular injury. In this syndrome, the possibility of nerve entrapment due to the heterotopic lesion should be considered as the cause of neuropathic pain. Early genetic testing for confirmation of the suspected diagnosis can avoid having to do an unnecessary biopsy.

Lipofibromatous hamartoma of the median nerve and its terminal branches: recurrent branch and ulnar proper palmar digital nerve of the thumb. A case report.

Lipofibromatous hamartoma (LFH) is a rare benign tumor affecting the peripheral nerves, particularly the median nerve. It is characterized by fatty tissue infiltrating the nerve. We report the case of a patient with LFH of the median nerve, recurrent branch and ulnar proper palmar digital nerve of the thumb associated with macrodactyly. It was responsible for hypoesthesia of the thumb's hemi-pulp and secondary carpal tunnel syndrome confirmed by electroneuromyography (ENMG). Diagnosis was suspected based on the MRI findings. The patient underwent surgical treatment consisting of open carpal tunnel release combined with neurolysis of the ulnar proper palmar digital nerve of the thumb. The extraneural LFH tissue was excised also. Forty-five days after surgery, the patient no longer had nocturnal paresthesia. Ninety days after surgery, sensitivity of the thumb pulp was satisfactory. Symptoms of LFH are related to the increased volume of the affected nerve. In the absence of symptoms, abstention seems to be the best option. In case of neurological clinical signs or ENMG abnormality, surgical treatment is indicated to perform neurolysis and excision of extraneural LFH tissue. The diagnosis is based on histological examination of tissue samples.

Revision surgery for carpal tunnel syndrome: a retrospective study comparing the combination of Canaletto® and Dynavisc® gel versus Dynavisc® gel alone.

The aim of this study was to assess the value of using a Canaletto® implant in combination with a gel composed of carboxymethylcellulose and polyethylene oxide in the surgical treatment of recurrent carpal tunnel syndrome (CTS). The case series included 31 patients with 32 hands operated for the second time for recurrent (22 cases) or recalcitrant (9 cases) CTS by neurolysis. The average patient age was 62 years. Dynavisc® gel alone was applied around the median nerve in the first 16 cases (Group I). The Canaletto® implant combined with Dynavisc® gel was used in the last 16 cases (group II). With an average follow up of 8 months (for group I) and 11 months (for group II), the pre/postoperative variation in pain assessed with a visual analog scale was 1.38/10 (group I) and 2.04/10 (group II), the QuickDASH score was 20.1/100 (Group I) and 20.48/100 (Group II), grip strength was 8% (Group I) and 20% (Group II), sensory nerve conduction speed was 23.20 m/s (group I) and 15.51 m/s (group II) and distal motor latency was 1.55 m/s (group I) and 1.21 m/s (group II). Ten patients recovered from hypoesthesia in both groups, 6 patients in group I and 2 patients in group II regained good trophicity of their superficial thenar muscles. Two patients from group II had not improved clinically although their electromyography had become normal. One patient from group II suffered a postoperative infection that required removal of the Canaletto® implant. He subsequently improved slightly. Our study found that for recurrent or recalcitrant CTS, the combination of Dynavisc® anti-adhesion gel around the median nerve and a Canaletto implant® after neurolysis results in outcomes that are as good as Dynavisc® alone, with a significant improvement of the QuickDASH score without the Canaletto®. In conclusion, the use of Dynavisc® gel alone around the median nerve after neurolysis seems to be as effective as other techniques described in literature but less invasive or time-consuming, and not associated with donor site morbidity such as the flexor tendon sheath.

Volar fracture dislocation of the 2nd metacarpal base associated with acute carpal tunnel syndrome: A case report.

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve.

The effect of mirror therapy after carpal tunnel syndrome surgery: A randomised controlled study.

The aim of this randomised controlled study was to investigate the effectiveness of mirror therapy (MT) on carpal tunnel syndrome (CTS) patients' symptoms and hand function after surgery. The patients' hand function was evaluated using the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) and the Nine Hole Peg Test. Their pain was evaluated using a visual analog scale, and their sensitivity was evaluated using the Semmes-Weinstein monofilament test before surgery, and at 3 and 6 weeks post-surgery. Thirty-five patients between the ages of 25 and 60 years were included in the study. In the control group (CTG) (n=17), the conventional physiotherapy program was applied for 4 weeks after 2 weeks of immobilisation. In addition to conventional physiotherapy, the MT group (MTG) (n=18) did MT during the immobilisation period. There were no statistically significant differences between the groups' demographic and clinical characteristics before treatment (P˃0.05). After treatment, all parameters improved in both groups. MTG had statistically lower pain at rest (P=0.004) and night-time pain (P=0.037) in the 3rd week, but there were no statistically significant differences between the other parameters and scores between the groups (P˃0.05). The study indicates improvement in the parameters due to the early introduction of MT after CTS surgery, but once conventional methods were started after immobilisation, there were no significant differences between groups. However, the MT had reduced pain and improved sensation and function. Both groups experienced positive effects of the surgical treatment and the physiotherapy in the 6th postoperative week.

Anatomy of the median nerve and its clinical applications.

The median nerve is a mixed sensory and motor nerve. It is classically described as the nerve of pronation, of thumb, index finger, middle finger and wrist flexion, of thumb antepulsion and opposition, as well as the nerve of sensation for the palmar aspect of the first three fingers. It takes its name from its middle position at the end of the brachial plexus and the forearm. During its course from its origin at the brachial plexus to its terminal branches, it runs through various narrow passages where it could be compressed, such as the carpal tunnel or the pronator teres. The objective of this review is to summarize the current knowledge on the median nerve's anatomy: anatomical variations (branches, median-ulnar communicating branches), fascicular microanatomy, vascularization, anatomy of compression sites, embryology, ultrasonographic anatomy. The links between its anatomy and clinical, surgical or diagnostic applications are emphasized throughout this review.

[Acute carpal tunnel syndrome caused by a thrombosis of a persistent median artery: 2 case reports]. / Canal carpien aigu : penser à la thrombose de l'artère persistante du nerf médian !

Carpal tunnel syndrome is a common peripheral neuropathy, usually idiopathic or post-traumatic due to the compression of the median nerve. Numbness and paresthesias in the median nerve distribution are the most common symptoms associated with this condition. Persistent median artery is a rare anatomic variation, thrombosis of this additional artery can be responsible for an acute carpal tunnel syndrome, and patients frequently complain about coldness and acute hand swelling. These unusual features must lead clinicians to think of a vascular cause. The diagnosis can be easily confirmed by using ultrasound doppler, but CT-scan and MRI are sometimes helpful. We describe 2 cases of acute carpal tunnel syndrome due to thrombosed persistent median artery, including a case of thromboangiitis obliterans. These thrombosis might also be due to traumatic causes. No guidelines are currently available to help physicians for the management of carpal tunnel syndrome from thrombosed persistent median artery. Antiplatelet therapy, statin, anticoagulant might be helpful, and surgery has sometimes be reported as effective.

Atypical schwannoma of the median nerve. A case report.

Schwannomas of the hand are very rare tumors and represent less than 3% of all soft tissue tumors in the hand. These tumors share clinical, epidemiological and imaging characteristics with the other soft tissue and peripheral nerve tumors; thus, it can be difficult to make a preoperative diagnosis. Here we report the case of a 48-year-old woman who presented with a schwannoma arising from the palmar branch of the median nerve. The tumor measured 54 × 41 x 52 mm and was located in the thenar eminence. The first hypothesis was a vascular tumor. After surgery and histological analysis, the final diagnosis of an atypical schwannoma was established. The presence of shared immunohistochemical characteristics with cellular histiocytoma and myoepithelial tumors forced us to adopt an aggressive follow-up protocol. As of the last follow-up at 9 years, the patient had good clinical outcomes and no recurrence. This case highlights the difficulties encountered in clinical practice to diagnose such tumors.

Revision surgery in carpal tunnel syndrome: a retrospective study comparing the Canaletto® device alone versus a combination of Canaletto® and Dynavisc® gel.

The aim of our study was to demonstrate the benefits of combining the Canaletto® implant with carboxymethylcellulose/polyethylene oxide gel in the surgical treatment of carpal tunnel syndrome (CTS) recurrences. Our case series included 39 patients (40 hands, one bilateral case) who underwent revision surgery for recurrent CTS (28 cases) or resistant CTS (12 cases). The mean age of the patients was 56 years. The Canaletto® only was implanted in the first 21 cases (group I). In the following 19 cases (group II), Dynavisc® gel was added to the protocol and applied around the median nerve when the Canaletto® was implanted. At 12 months' follow-up (group I) and 11 months' follow-up (group II), the pre-versus post-operative difference between the average values of the DN4 neuropathic Pain Score was 0.55/10 in group I and 2.25/10 in group II; the Pain Score was 2.23/10 (in group I) and 2.52/10 (in group II); the Quick DASH Score was 18.98/100 (group I) and 19.06/100 (in group II); the hand grip strength was 19.55% (group I) and 28.53% (group II); the sensory nerve conduction velocity was 8.67 m/s (group I) and 10.27 m/s (group II); the distal motor latency was 1.05 m/s (group I) and 1.75 m/s (group II). Nine patients recovered from hypoesthesia in both groups, 5 patients regained satisfactory trophism of the thenar muscles in group I and 3 patients in group II. No improvement whatsoever was noted in 2 patients in group II, despite the electromyogram being normal. One patient from group II suffered an infection that required revision surgery to remove the Canaletto®; this led to a moderate improvement. Our results show that when resistant or recurrent CTS is diagnosed, the combined treatment of an anti-adhesion gel such as Dynavics® around the median nerve with the Canaletto® implant after performing secondary neurolysis leads to satisfactory post-operative outcomes. Compared to other techniques described in the current literature, our technique is less invasive, quicker and associated with minimal morbidity of the surgical site.

Tenosinovitis inespecífica en granos de arroz de los tendones flexores de la mano / Ténosynovite non spécifique d'aspect en grains de riz des tendons fléchisseurs de la main / Non-specific flexor tendons tenosynovitis in rice grains of the hand

La tenosinovitis con cuerpos libres en forma de granos de arroz es una afección muy infrecuente que se presenta, generalmente, asociada a artritis reumatoide o tuberculosis. Los casos no asociados a estas enfermedades son extremadamente raros. Se presenta un paciente masculino de 62 años de edad, intervenido quirúrgicamente por un síndrome del túnel carpiano derecho hace 7 años. En aquel momento se le realizó una apertura del retináculo transverso del carpo y una sinovectomía de los tendones flexores. La biopsia sinovial reportó una "sinovitis crónica". Evolucionó satisfactoriamente durante los primeros 4 años, luego comenzó a presentar nuevamente los síntomas compresivos del nervio mediano y un aumento progresivo del volumen en la cara anterior de la muñeca. El ultrasonido mostró una marcada hipertrofia sinovial de los tendones flexores a nivel de la muñeca. Los estudios neurofisiológicos reportaron daño axonal y mielínico en las fibras del nervio mediano derecho. Se le realizó una nueva intervención donde se visualizó la hipertrofia sinovial y abundantes cuerpos libres en forma de granos de arroz agrupados en sacos sinoviales. Se le descomprimió el túnel carpiano, se resecaron los cuerpos libres y se le hizo una sinovectomía amplia. El resultado de la biopsia fue una sinovitis inespecífica con cuerpos libres en granos de arroz. Después de dos años de operado el paciente está asintomático.

Tenosynovitis with loose rice grain-like structures is a very rare condition that usually presents associated with rheumatoid arthritis or tuberculosis. Cases not associated with these diseases are extremely rare. A 62-year-old male patient underwent surgery for a right carpal tunnel syndrome seven years ago. At that time, an opening of the transverse retinaculum of the carpus and synovectomy of the flexor tendons were performed. Synovial biopsy reported "chronic synovitis". It evolved satisfactorily during the first four years; then the patient began to present again the compressive symptoms of the median nerve and progressive increase in volume in the anterior aspect of the wrist. The ultrasound showed marked synovial hypertrophy of the flexor tendons at the level of the wrist. Neurophysiological studies reported axonal and myelin damage in the fibers of the right median nerve. A new intervention was performed. Synovial hypertrophy was visualized and abundant free loose rice grain-like structures grouped in synovial sacs. The carpal tunnel was decompressed, the free bodies were resected and wide synovectomy was performed. The result of the biopsy was non-specific synovitis with free rice grain-like structures. After two years of surgery, the patient is asymptomatic.

La ténosynovite à corps étrangers libres d'aspect en grains de riz est une affection très peu fréquente, étant généralement associée à l'arthrite rhumatoïde ou à la tuberculose. Les cas non associés à ces maladies sont extrêmement rares. Le cas d'un patient âgé de 62 ans, atteint de syndrome du canal carpien droit, et traité chirurgicalement il y a sept ans, est présenté. En ce moment-là, il a subi une incision du ligament transverse du carpe (rétinaculum) et une synovectomie des tendons fléchisseurs. La biopsie synoviale a dévoilé une «synovite chronique¼. L'évolution a été satisfaisante au cours des quatre premières années; puis après la compression du nerf médian et l'inflammation progressive de la face antérieure du poignet ont réapparues. L'échographie a montré une marquée hypertrophie synoviale des tendons fléchisseurs au niveau du poignet. Les examens neurophysiologiques ont révélé un dommage axonal et myélinique des fibres du nerf médian droit. Dans la nouvelle intervention effectuée, une hypertrophie synoviale et plusieurs corps étrangers d'aspect en grains de riz groupés en bourses synoviales ont été remarqués. Une décompression du canal carpien, une résection des corps étrangers et une large synovectomie ont été réalisées. La biopsie a repéré une synovite non spécifique à corps étrangers libres en forme de grains de riz. Le patient reste encore asymptomatique depuis deux ans.