Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Clinical results of a new technique using an endoscopic carpal tunnel release device.

Exertional compartment syndrome of the forearm is a rare pathology, occurring almost exclusively in motorcycle racers. The results of endoscopic techniques are similar to those of open fasciotomies, but they are less invasive and leave smaller scars. The aim of our study was to present a new endoscopic technique for superficial fasciotomy using the Agee® system and to describe the results. This was a single-center, retrospective descriptive study of 21 patients (36 forearms) operated on between 2006 and 2016. All patients but one were competitive motorcycle racers. The mean operating time was 38.2min (standard deviation (SD), 10.5min). The QuickDASH score was 23.3±10.2% preoperatively versus 1±2% postoperatively (mean±SD). Among the 18 patients who came back for a follow-up visit after 4.9±2.7 years, 17 (94%) were satisfied or very satisfied. The mean time before returning to sport was 4.3 weeks (SD, 1.8 weeks), 9 patients (50%) at the same level as before surgery, 8 (44%) at a higher level, and one at a lower level. There were a few minor complications (superficial vascular lesions, hematoma, transitory hypoesthesia) and symptoms recurred in two patients. Our technique yields outcomes similar to those of other published endoscopic procedures and allows early return to sport. It has the advantage of being based on the Agee endoscope, which is commonly used to treat carpal tunnel syndrome, making the procedure easy to master.

[Hetero-digital toe flap according to the « spare-part ¼ concept taken from a duplicated toe for the treatment of a cutaneous flessum of an associated clinodactyly]. / Lambeau hétéro-digital selon le principe du « doigt banque ¼ prélevé chez un orteil dupliqué pour le traitement d'un flessum cutané d'une clinodactylie associée.

INTRODUCTION: The correction of cutaneous deficiency encountered in clinodactyly is an important aspect of its treatment. The use of the skin lining of an adjacent duplicated toe as a « spare-part ¼ flap may be of interest in providing good quality tissue. CLINICAL CASE: We report the case of a child with complete duplication of the 5th toe associated with clinodactyly. The use of a heterodactyl flap taken from the amputated toe allows the release of a plantar cutaneous flange of the preserved toe. DISCUSSION: The concept of « spare-part ¼ flap is mainly used in hand surgery in traumatic lesions of the fingers. Its application in the treatment of clinodactyly on the occasion of the regularization of a polydactyly is also interesting because some fingers or toes are intended to be amputated to render a classical anatomy of five-toed foot. It is necessary for the realization of this type of flap on malformative toes to verify the existence of a distinct viable pedicle of the amputated toe, which can be done only intraoperatively. CONCLUSION: The surgery for congenital malformations of the toes requires perfect management of the skin capital. The use of a « spare-part ¼ toe flap taken from the toe to be amputated is a viable solution for the treatment of a cutaneous flessum encountered in a clinodactyly of the adjacent finger.

[The modified Lamberty and Cormack's flap for neuropathies of the ulnar nerve at the elbow]. / Le lambeau de Lamberty et Cormack modifié dans les neuropathies du nerf ulnaire au coude.

Surgical treatment of ulnar nerve syndrome at the elbow gives good results in the majority of cases but there are sometimes incomplete results or recurrences that can lead to iterative procedures. This iterative surgery is responsible for painful neurological sequelae often resistant to pharmacological treatments. In these selected resistant cases, we made the choice of a surgical treatment associating a neurolysis of the ulnar nerve and wrapping with a vascularized flap modified from Lamberty and Cormack. This retrospective study focused on six cases with an average follow-up of 30 months. The results showed an improvement in all patients, especially for the two criteria which best reflect the neuropathic pain: DN4 questionnaire and the visual analog scale of pain. Even if it is a short study, it commits us to continue to apply the principle of covering ulnar neuropathy at the elbow by a vascularized flap.

[Bone quality evaluation in allograft hand transplant]. / Évaluation de la qualité de l'os dans les allogreffes de main.

Five bilateral forearms allograft have been performed between January 2000 and July 2009 in Lyon (France). The first four patients (three males, one female) have been the subject of an assessment of the bone quality of those allografts. The techniques selected for this study were: radioclinical analysis, bone scintigraphy, MRI, bone densitometry and High Resolution peripheral Quantitative Computed Tomography (HR-PQCT). Histology has been performed only on the first patient unilaterally grafted in 1998 who did not take part in this clinical research protocol, after amputation of his rejected graft. On the clinical, radiological and scintigraphical aspects, donor bone integration in hands allograft are good on a macroscopic point of view considering the healing and the general reaction of the bone in situation of fractures, infection and growth. The scintigraphy does not show important variations compared to the ones we can observe on contact with osteosynthesis material or during bone autografts. MRI found neither focal nor periosteal anomaly on grafted bone. The bone densitometry did not show significant difference with secondary osteoporosis one can observe in other grafted patients under immunosuppressive treatment. The HR-PQCT showed for the three males patients, a higher loss in volumetric density, for grafted bone than in the recipient patient control skeleton. Due to the few patients of this series, and the discrepancies in follow-up duration, the presented data have to be confirmed with further studies.

[Hand allografts: experience from Lyon team]. / Allogreffe de mains: expérience lyonnaise.

Hand allograft is a method in the stage of clinical experimentation, which is reserved in France for the treatment of bilateral traumatic amputees. This study reports the Lyon team experience, which is pioneer in this domain. Four patients (3 males and 1 female) underwent seven (one unilateral and three bilateral) hand transplantations from September 1998 to February 2007. The level of amputation was at the wrist or at the mid-forearm. Delay since hand loss ranged from 2.5 to 9 years. The surgical protocol was elaborated and planned case by case. All recipients received the same immunosuppressive treatment. Episodes of acute rejection were observed in the first 3 months after transplantation, which were easily managed after a few days increasing oral prednisone doses and applying topical immunosuppressants. Currently the patients receive the doses of immunosuppressants comparable to those in kidney-grafted patients. We have not registered any severe complication of immunosuppressive treatment up till now (7 years follow-up for the earliest graft). We performed analytical and functional clinical, as well as questionnaire evaluation of patients. The first case (unilateral graft) resulted in graft failure at 2 years due to non-compliance of the patient. The three bilateral graftees demonstrate a favorable evolution despite some immunological (hyperglycemia, serum sickness) and surgical (thrombosis, osteomyelitis, skin loss) complications, which could be managed. The middle and long-term follow-up evaluation revealed good to excellent sensorimotor recovery of 4 hands in both male recipients (4 and 7 years) with satisfactory social adaptation, higher or equal to those expected after post-traumatic replantations at the equivalent level and higher to those obtained with currently available myoelectric prosthesis. The last patient, a young female who has been grafted in February 2007, receives ongoing reeducation course and shows normal progress of functional restoration of both hands. The encouraging results of this clinical experimentation make us currently consider hand allografting as reasonable and useful both for the patients and for evolution of research in composite tissues allotransplantation (CTA). Further long-term careful research and worldwide monitoring of all patients with hand allografts is required to, on the one part, state on the authorization of this surgery, and, on the other part, to better elucidate the mechanisms of successful CTA.

[Primary Swanson metacarpophalangeal joint arthroplasty in major hand traumas. A report of two cases at 14 years follow-up]. / Arthroplasties métacarpophalangiennes en urgence par implant de Swanson dans les traumatismes pluritissulaires complexes de la main. A propos de deux cas revus a 14 ans.

In major hand injuries, destroyed joints may be treated by joint transfer, arthroplasty or fusion with or without temporary external fixation. Four immediate digital metacarpophalangeal joint Swanson implants in two patients with amputation or devascularizated near-amputation were reviewed with a 14 years follow-up. No infection was noted. Prostheses were stable with a 31 degrees active range of motion and grip strength was 42% of the opposite side. Functional results were "useful" with patients satisfaction. In one patient, heavy manual worker, implants were replaced fourteen years after trauma because of recent pain on one joint and implants fragmentation. The other patient was painless. Immediate Swanson arthroplasty in major hand injuries may be an alternative in metacarpophalangeal joints destruction.

[The first transplantation of a hand in humans. Early results]. / Première transplantation de main chez l'homme. Résultats précoces.

The first hand allograft was performed on September 23, 1998. The right distal forearm and hand of a brain dead donor was transplanted to a 48 year old recipient who had undergone a traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with organ preservation solution (UW) and transported to Lyon in a cool container. Two teams simultaneously dissected the donor's limb and the recipient's stump to identify anatomical structures. Transplantation involved bone fixation, arterial and venous anastomoses, nerve sutures, joining of the muscles and tendons, and skin closure. Immunosuppression consisted of anti-lymphocyte, polyclonal and monoclonal antibodies, tacrolimus, mycophenolic acid, and prednisone. Mild clinical and histological signs of rejection occurred at week 9 after surgery. They disappeared with adjustments of the immunosuppressant doses. Seven months after surgery the patient was in good general condition. Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress is excellent, reaching the fingertips. A longer follow-up is necessary to appreciate the final result. In the absence of further rejection, the functional prognosis of the graft should be similar to that reported after successful autoreconstruction.