Clinical and functional outcomes of surgical treatment of grade III ulnar collateral ligament injuries of thumb metacarpophalangeal joint.

OBJECTIVES: The aim of this study was to compare the clinical and functional outcomes of three surgical techniques (subperiosteal suture, bone anchor and direct repair) for the management of severe acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with a minimum of 1 year follow-up. MATERIAL AND METHODS: Between 2015 and 2020, 230 collateral ligament injuries required surgical treatment in our department. After the inclusion and exclusion criteria were applied, 100 were included in the study. The Glickel score and functional scores such as QuickDASH and PRWE were assessed. Time to return to work and to sport was quantified. RESULTS: Ulnar collateral ligament injuries affected men who were statistically younger than women (41.8 years old vs 48.3). Subperiosteal suture was the preferred technique (81%), then bone anchor reattachment (12%) and direct repair (7%). All three techniques produced excellent stability (91-100%). Better range of motion was reported in the subperiosteal group, but better strength was found in the bone anchor group. Subperiosteal suture had 89% excellent and good results, while there was 83% in the bone anchor group and 71% in the direct repair group. Mean time to return to work was 2 months in the bone anchor group versus 3 months in the subperiosteal group. Mean QuickDASH was 8.7/100 and mean PRWE was 7.1/100. CONCLUSION: This is the biggest case series to date on surgical treatment of severe ulnar collateral ligament injuries of the thumb metacarpophalangeal joint. The subperiosteal technique is simpler and less expensive. While the results are not often described in the literature, it produces comparable clinical and functional outcomes to bone anchor reattachment with a minimum follow-up of 1 year.

Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series.

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

General principles of tendon transfers: The ten commandments.

Transferring a muscle's point of force application by modifying its distal insertion will modify its function. This is the basic principle of tendon transfers. Despite being less popular due to superior primary nerve repair results, hand surgeons must be familiar with them. When used according to the Ten Commandments we propose, they provide good and useful functional recovery. Obviously, it depends on the number of muscles available for transfer. Tendon transfer is useful not only in nerve trunk palsy and brachial plexus lesions but also in upper limb tetraplegia rehabilitation. Tendon transfers are active palliative treatments under voluntary command and can be combined with other palliative procedures (arthrodesis, tenodesis) to improve the functional result. Nevertheless, they are far from ideal, as they re-allocate the remaining forces of the limb but do not create new ones.

Intermetacarpal M4-M5 arthrodesis (Dubert procedure) for fifth carpometacarpal joint osteoarthritis: long-term functional outcomes.

The goal of this study was to describe the long-term functional outcomes of the procedure described by Dubert (stabilized arthroplasty with intermetacarpal arthrodesis) for painful carpometacarpal impingement of the little finger. Between 2005 and 2017, 8 patients (1 woman and 7 men) were operated on who had a mean age of 38 years (24-53 years). Seven cases were post-traumatic (malunion) and one was due to septic arthritis. A total of 5 patients were available for a retrospective clinical, functional, and radiological follow-up at a mean of 73 months (23-108 months). Clinical parameters included pain on VAS, grip strength, Quick Disability of Arm, Shoulder and Hand questionnaire, Patient-Rated Wrist Evaluation, and a subjective hand value (0-100%). Fusion was achieved in all cases. Of the 8 patients, one developed complex regional pain syndrome and one had persistent pain that required secondary proximal metacarpal resection. At the last follow-up, all patients were satisfied and reported a significant reduction in pain and improvement in strength. Mean Quick Disability of Arm, Shoulder, and Hand questionnaire, Patient-Rated Wrist Evaluation and subjective hand value were 19/100 points, 21/100 points and 75%, respectively. Our study suggests that the stabilized arthroplasty of the fifth finger, as describe by Dubert, is an efficient and reliable method to reduce pain and improve hand function in patients suffering from carpometacarpal impingement of the little finger. LEVEL OF EVIDENCE: retrospective series, IV.

Clinical, functional, and radiological results of the Amandys® interposition arthroplasty in 13 cases of wrist osteoarthritis.

Amandys® pyrocarbon interposition arthroplasty is intended for widespread arthritis of the wrist. The aim of this study was to assess the clinical, functional, and radiological results of this arthroplasty with a minimum follow-up of 12 months. This retrospective single-center study brought together all osteoarthritis indications that can benefit from an Amandys® arthroplasty. Twenty-one implants were used between January 2011 and October 2018. There were seven cases of distal radius malunion, eight SLAC wrists, two SNAC wrists, two cases of Kienböck's disease at Lichtman's stage 4, and two aftermaths of inflammatory arthritis. Twenty-four percent of patients had previously undergone another type of surgery for this wrist arthritis. Six implants were removed, five early for dislocation and one after 6 years for chronic pain. Thirteen patients were reviewed with an average follow-up of 40.7 months (21-90). The average pain level on a visual analog scale was 3.1/10 (0-7). The mean range motion was 36° flexion (10-60) and 33° extension (15-50). The mean grip strength at the last follow-up was 14.8 kg (2-30) (43% of contralateral). The average QuickDASH and PRWE functional scores were 37.9/100 (0-80) and 29.6/100 (0-83.5), respectively. Amandys® interposition arthroplasty is an interesting alternative to total wrist fusion or total wrist prosthesis for widespread arthritis of the wrist. For the implant to be stable, the capsulo-ligamentous systems must be intact.

Upper limb compartment syndrome after a viper bite in a child: A case report.

The occurrence of compartment syndrome after a viper bite is a rare phenomenon and its treatment remains controversial. We report the case of an 11-year-old boy who developed compartment syndrome of the right upper limb following a viper bite. Decompression by fasciotomy was performed urgently with a good outcome. Surgical decompression for compartment syndrome following a viper bite is not a common treatment according to the literature. Fast access to care and antivenom administration seem to be effective at treating the compartment syndrome without recourse to fasciotomy.

[Results of Blauth Palmar Flap in congenital syndactyly: Long-term outcome in a 31 webs study]. / Évaluation du lambeau palmaire de Blauth lors de la prise en charge des syndactylies congénitales : à propos de 31 commissures.

OBJECTIVES: The main purpose of our study was to assess the web creep rate of congenital syndactyly treated with a Blauth palmar commissural flap. METHODS: Every child with at least one syndactyly, simple or complex, syndromic or not, were included in this study. The main criterion of this study was the web creep rate according to the Withey scale (0 to 4). Scar assessment according to the Vancouver Scar Scale, hair growth and/or dyschromia on the full-thickness graft, digital spacing, flexion deformity, clinodactyly, range of motion of the finger, sensitivity and satisfaction were also assessed. RESULTS: Separation of the webbed fingers was performed in 65 syndactylies between 1993 and 2015. The median age at the time of surgery was 14 months. We reviewed 31 web flaps with a mean follow-up time of 9 years. Fifty eight percent of the webs were grade 0 on the Withey scale, 36% were grade 1, 6% were grade 2. There was no grade 3 or 4. No correlation was found between the age at the time of surgery, gender, web space involved, complexity of the syndactyly, and the web creep. A decrease in range of motion and a flexion deformity of the fingers involved were more frequently found in complex syndactylies. Eighty seven percent of full-thickness grafts presented dyschromia, and 42% abnormal pilosity. CONCLUSION: Palmar flap as described by Blauth is a safe technique ensuring good functionals outcomes and a low web creep rate for the reconstruction of the web space in congenital syndactyly.

Short- and long-term results of common peroneal nerve injuries treated by neurolysis, direct suture or nerve graft.

INTRODUCTION: Damage to the common peroneal nerve is the most frequent nerve injury in lower limb traumas. Our objective was to assess the motor and sensory recovery levels and the functional outcomes after remedial surgery for common peroneal nerve trauma, through either neurolysis, direct suture or nerve graft. METHODS: This is a transversal, observational study of a monocentric cohort of 20 patients who underwent surgery between January 2004 and June 2016, which included 16 men and 4 women whose median age was 35 ± 11 years. We assessed the level of sensory and motor nerve recovery and the Kitaoka score. Nine patients benefited from neurolysis, 5 had direct sutures, and 6 received a nerve graft. RESULTS: With 48 months' average follow-up, 7 out of 9 patients underwent neurolysis and 4 out of 5 with direct sutures had good motor recovery (≥ M4), but none for the grafts. Sensory recovery (≥ S3) was satisfactory in 7 out of 9 cases in the neurolysis group, 3 out of 5 in the direct suture group, and 3 out of 6 in the nerve graft group. The average Kitaoka score was 83.7 ± 11.5 for the neurolysis group, 86.8 ± 16 for the direct suture group, and 73 ± 14 for the graft group. CONCLUSION: Surgical treatment by neurolysis and direct suture yields good results with a motor recovery ratio nearing 80%. When a nerve graft becomes necessary, recovery is poor and resorting to palliative techniques in the shorter run is a strategy which should be evaluated.

Long-term outcomes of proximal row carpectomy: A series of 62 cases.

The aim of this study was to determine and analyze the functional and radiographic outcomes after proximal row carpectomy (PRC). We hypothesized that this surgery could restore wrist mobility and function in case of radiocarpal osteoarthritis or severe carpal trauma. Sixty-two patients who had undergone PRC were included in this study: 44 patients with wrist osteoarthritis (11 SNAC, 24 SLAC, 3 Kienböck's disease, 6 other) and 18 patients with severe carpal trauma. Each patient underwent clinical (pain, range of motion, grip strength, functional scores) and radiographic evaluations. At the latest evaluation after a mean of 11.8 years, 15 patients (24.2%) required revision total wrist arthrodesis surgery in a median of 22 months (range, 6-179) because of disabling pain and lack of strength. The failure was statistically correlated with being young and a manual laborer. The range of motion and strength of the operated wrist were 61.5% and 70%, respectively, compared to the contralateral side. PRC remains a reliable procedure for treating wrist arthritis and severe carpal trauma. However, manual activity and being under 50years of age can lead to an early salvage procedure such as total arthrodesis of the wrist. In this subset of the population, another alternative must be considered.

Upper limb nerve transfers: A review.

While upper limb nerve transfers were first described and performed several years ago, they have seen expanded use in the past 20 years. Initially indicated for surgical repair of brachial plexus injuries with nerve root avulsion, the indications have been extended to post-ganglionic lesions because of the excellent results of certain intraplexus nerve transfers. The traditional nerve repair techniques - primary suture and nerve grafting - form the basis of nerve surgery. Although nerve transfer does not replace them, they are a useful supplement as they provide a targeted approach to reinnervation and recovery of key functions of the upper limb. The goal of this review is to provide an overview of the various possible transfers by the function being restored and the quality of the outcomes.

Recovery of rock climbing performance after surgical reconstruction of finger pulleys.

UNLABELLED: This study evaluated recovery of sport performance and correction of bowstringing after surgical reconstruction of closed finger pulley rupture in high-level rock climbers. A total of 38 patients treated with an extensor retinaculum graft were assessed. The mean follow-up time was 85 months, and 30 patients returned to their previous climbing level. The mean total active motion score was 96% of the opposite side. All patients had an excellent Buck-Gramcko score. There was no significant difference in grip strength and tip pinch strength in the crimp position between the injured side and the opposite side. A total of 31 patients were examined with ultrasonography. In 18, flexor bowstringing effects had returned to near-normal values. There was an association between rock climbing level recovery and the flexor bowstringing correction (odds ratio, 6.9; 95% confidence interval, 1.1-42.8). If flexor bowstringing was corrected, patients were more likely to regain their preinjury sport performance. The ultrasonography measurement was a useful tool for predicting functional recovery. LEVEL OF EVIDENCE: 4.

Results with the Roseland(®) HAC trapeziometacarpal prosthesis after more than 10 years.

The Roseland(®) hydroxyapatite-coated prosthesis is a total trapeziometacarpal joint prosthesis used for the surgical treatment of thumb basal joint arthritis. The aim of this retrospective study was to evaluate its long-term outcomes. Fifty-one patients (64 thumbs) underwent trapeziometacarpal joint replacement with this prosthesis. The mean follow-up was 12.5 years. Survival rate of the prosthesis was 91%. There was either no pain or only occasional pain in 91% of cases. The mean QuickDASH score was 27.6. Abnormal radiographic findings were present in 70% of cases. Since they were often asymptomatic, no further treatment was carried out. Complications were common (25%) and occurred early on but could often be treated without surgery. The long-term results with the Roseland(®) HAC prosthesis are satisfactory in terms of pain relief and function. However, the high complication rate is a major concern.

[Lower limb salvage with a free fillet fibula flap harvested from the contralateral amputated leg]. / Un cas de "jambe-banque" pour le sauvetage d'un membre inférieur.

We report a unusual case of "fillet flap" to reconstruct the lower limb with the amputated contralateral leg. This kind of procedure was first described by Foucher et al. in 1980 for traumatic hand surgery as the "bank finger". A 34-year-old man suffered a microlight accident with bilateral open legs fractures. A large skin defect of the left leg exposed the ankle, the calcaneus and a non-vascularized part of the tibial nerve (10 cm). The patient came to the OR for surgical debridement and had massive bone resection of the left calcaneus. The right leg showed limited skin defect at the lower part, exposing the medial side of the ankle and a tibial bone defect, measuring 10 cm. Salvage the left leg was impossible due to complex nerve, bones and skin associated injuries, so this leg was sacrificed and used as a donor limb, to harvest a free fibula flap for contralateral tibial reconstruction. At 18 months of follow-up, the patient was very satisfied, the clinical result was very good on both lower limbs and X-rays showed excellent integration of the free fibula flap. The patient had normal dailies occupations, can run and have bicycle sport practice with a functional left leg fit prosthesis. This case showed an original application of the "fillet flap concept" to resolve complex and rare traumatic situations interesting the both lower limbs. In our opinion, this strategy must be a part of the plastic surgeon skills in uncommon situations.

[Management of zone 1 flexor digitorum profundus tendon injuries]. / Prise en charge des lésions du tendon fléchisseur profond des doigts en zone 1.

Flexor tendons repair in zone 1 is classically considered providing good results with an overall satisfactory finger function. However, the objective functional results after surgical repair of flexor digitorum profundus are sometimes disappointing. The authors describe the different surgical repair techniques available to the operator from so-called "traditional" sutures to newer methods of internal fixation using miniaturized anchor sutures. The management of postoperative procedures, that of failures and old cases are reported.

[Flexor tendon repair: a short story]. / Une histoire de la réparation des tendons fléchisseurs.

This short story of flexor tendon repair aims to illustrate hesitations and wanderings of this surgery. Obviously tendon repair was very early considered, but it developed and diffused rather lately. It became a routine practice only in 20th century. This was due on the one hand, in Occident, to the Galen's dogmatic interdiction, on the other hand, to the repair difficulties of this paradoxical structure. Actually tendon is made of fibroblasts and collagen (sticky substances), and then its only goal is to move. According to this necessity, whatever the used techniques are, gliding is the final purpose. Technical evolutions are illustrated by historical contributions to flexor tendon surgery of several "giants" of hand surgery.

[Secretan's syndrome: myth or pathomimia?]. / Le syndrome de Secrétan : mythe ou pathomimie ?

UNLABELLED: Secretan's syndrome is a rare condition involving generally trauma-induced hard edema of the dorsal aspect of the hand. The cause is poorly understood but factitious trauma is often suspected. CASE REPORT: A 42-year-old woman presented with a fortuitous edema on the back of the right hand. The minimally depressible edema was associated with moderately intense mechanical pain. Routine laboratory tests were normal. An extensive imaging work-up (bone x-ray of the hand and wrist, bone scintigraphy, computed tomography phlebography, lymphoscintigraphy, magnetic resonance imaging) was equally non-contributive. The diagnosis of self-inflected trauma was suggested by the atypical nature of the edema, the absence of any organic disorder on the tests performed, and the patient's attitude concerning her disease. In this clinical context, the diagnosis of Secretan's syndrome was retained. Outcome was compatible, with secondary development of complex regional pain syndrome. DISCUSSION: Three forms of Secretan's syndrome have been recently described: benign; hyperplastic; and mixed. The cause remains poorly defined. Certain authors report that it is most likely related to pathomimia. Treatment can combine physiotherapy and psychological counseling. CONCLUSION: Secretan's syndrome is a poorly-understood and rarely-described condition that may be underdiagnosed. Physicians specialized in vascular medicine should be aware of this syndrome and its difficult diagnosis by elimination.

[Foreign body reaction in osteoarthritis of the trapeziometacarpal joint treated by trapezectomy and interposition of a L-polylactic acid "anchovy" (Arex®615R). A series of eight cases]. / Réaction à corps étranger dans les rhizarthroses traitées par trapézectomie et interposition d'un « anchois ¼ en acide L-polylactique (Arex®615R). À propos de huit cas.

Osteoarthritis of the trapeziometacarpal joint is a common pathology. When the trapezium is not large enough to allow using a total joint arthroplasty or in case of peritrapezial osteoarthrosis, the authors used a trapeziectomy with interposition of an absorbable L-polylactic acid anchovy (Arex(®)615R). This technique is simple and fast. From 2006 to 2010, out of 68 implants, nine displayed a prolonged inflammatory reaction, both clinically and radiologically abnormal, leading the patients to undergo revision surgery for removal of the implant before the end of the third postoperative year. Histological analysis highlighted in all the cases a resorptive gigantocellular immune foreign body reaction.

[Necrotizing fasciitis: study of 17 cases presenting a low mortality rate]. / Dermo-hypodermite bactérienne nécrosante avec fasciite nécrosante : à propos de 17 cas présentant un faible taux de mortalité

UNLABELLED: Necrotizing fasciitis is a hypodermis, muscular fascia then dermis necrotizing infection. OBJECTIVE: The originality of this study is to present a series of necrotizing fasciitis treated and followed these last five years, and to compare the therapeutic results with those of the literature. PATIENTS AND METHODS: We led a retrospective study on the patients treated for necrotizing fasciitis between 2005 and 2009 by bringing together the demographic and clinical data, the bacteriological examinations and the results of management. Follow-up data from these patients during period of study (five years) were notified. RESULTS: Seventeen patients were treated (11 men and six women). The average age of the patients was 52 years (ranging from 28 to 82 years). Risk factors of necrotizing fasciitis for our patients were: nonsteroidal anti-inflammatory drugs (82.2%), cutaneous wound (76.4%), obesity (29.4%), oto-rhino-laryngologic diseases (23.5%), alcoholic and drug addicts (23.5%), and diabetis (11.7%). The most isolated and responsible germ was Streptococcus pyogenes in 75.5% of cases. Culture of specimens collected before antibiotic treatment showed that the bacterium was sensible to the antibiotics being administered (clindamycin in 70.5% of cases). The surgical management was early done with an average delay of 2.7 days (ranging from 1 to 15 days). We observed a low mortality rate (11.7%). One patient died during the period of follow-up after one year (average follow-up of 2.0 years; 1-3 years). CONCLUSION: Contrary to the data from the literature, this study presents a decrease of the mortality in necrotizing fasciitis with an early treatment and an adequate management. The precocity and the quality of surgical procedures as well as the presence of an underlying disease are determining factors for successful management of necrotizing fasciitis.

[Necrotizing soft tissue infection of the upper limb]. / Dermo-hypodermites bactériennes nécrosantes et fasciites nécrosantes du membre supérieur.

Necrotizing soft tissue infections and necrotizing fasciitis are life-threatening infections affecting the hypodermis, muscular fascia, and dermis secondarily. Mortality is high, with an average of 30%. The early diagnosis of necrotizing soft tissue infection is challenging, but is key to successful management of these patients. The mainstay of therapy includes early and wide surgical debridement, antibiotics and supportive care. Adjunctive therapies may have a role, but their effectiveness remains unproven. A review of the literature allows us to highlight this multidisciplinary management.

[Roseland® prosthesis: quality of life's studies about 68 patients with a mean followed-up of 43.8 months]. / Prothèse Roseland®: étude de qualité de vie de 68 patients avec un recul moyen de 43,8 mois.

OBJECTIVES: Roseland® prosthesis is a ball and socket prosthesis, physiological and not anatomical. This study wants to demonstrate by a quality life questionnaire (quick DASH described by Dubert et al., 2001) that Roseland® prosthesis gives to patients a trapeziometacarpal joint native capacities. PATIENTS AND METHODS: An exterior examinator reviewed prospectively 68 patients having a mean age of 61.1 years at surgery with 11 bilateral cases that is 79 prothesis. With a mean follow-up of 43.8 months, we value by Kapandji's opposition, first comisssural openning, quality of life and patient's satisfaction. RESULTS: Three patients have been excuded: two of them had got post-traumatic dislocation: one trapezium fracture, one unknown reason. The third patient had got osteophytis with "came" effects. We keep 65 patients with 84,6% satisfying and very satisfaying. 75,4% of patients have a capacity of 80% and more of their joint, 40% of them had got 100%. DISCUSSION: Roseland® prosthesis has good results because it agrees with already known principles as on its own concept: rotula prothesis gives three axes mobility, as on its own conception: metarcarpal stem with a palmar "T" shaped against rotation and bone saving, a cup with equatorial ring to prevent burying of the spongy bone. Componenents are recovered by hydroxyapatite to favour osteo-integration with less loosening than ciment. An accurate technique avoids dislocations traps: trapezium implant centring, internal osteophytis removal. An accurate indication: trapeziometarpal joint osteoarthritis only (second degree's Dell classification). CONCLUSION: Roseland® prosthesis reproduces a satisfactory and functional joint for 84,6% of cases. These good results can be obtained by accurate indication (Dell II) and contra-indication (osteoarthritis around trapezium except trapeziometacarpal of course).