Modeling and concepts of the Malingue plasty compared to Z-plasty.

Malingue's diamond-shaped skin plasty is a random skin plasty derived from the Z-plasty. Not widely known, this technique is an alternative to fasciectomy in Dupuytren's disease. The main objective of the present study was to analyze the topographical and anatomical differences between Z-plasty and Malingue plasty in cadaveric and experimental models and the geometrical and mathematical differences in modeling, in order to determine the respective gains in length. The study was carried out in two steps. An anatomical step on a cadaveric model studied vascularization. The second step was based on inert models (latex gloves) and cadaveric models, to study the mechanical behavior of the flaps. Differences in gains in length were analyzed by Euclidean and non-Euclidean geometry. The Malingue plasty flaps showed greater vascular richness than in Z-plasty. The experimental cadaver and inert material models showed 50% length gain with a single Malingue plasty, versus 33.3% with Z-plasty. The gain decreased in multiple plasties: respectively, 25% and 17.5% with double plasty and 20% and 16.7% with triple plasty. The analysis of Euclidean plane geometry did not explain these results, whereas 3D analysis on non-Euclidean geometry can explain a superior elongation effect in the Malingue plasty. The Malingue plasty could be an interesting option when significant lengthening is required, especially when Z-plasty would be insufficient.

Learning, teaching, and training in microsurgery: A systematic review.

Numerous microsurgical training techniques and materials have been developed to reduce animal use and training costs. This systematic review aimed to catalog the available microsurgery learning methods on non-living material in order to define an educational program. The PubMed database was searched for English and French articles related to the initial learning of microsurgery with inert, non-living, or digital material and containing the keywords "microsurgery", "non-living", "simulation" and "virtual reality". Among the 488 articles found, 82 were included. This work reports the main microsurgery learning supports. They were classified according to the material used: inert material, cadaveric animal tissues, human cadaver model, virtual reality, and digital technologies. The educational program proposes here is a two-step program that uses non-living material (basic and deepening) before progressing to living models. This initial learning phase teaches basic microsurgical skills (precision, tremor management, and magnification). Then, frequent home training sessions help to maintain the acquired skills. Ethical, organizational, and economic constraints limit access to animal models. Therefore, inert models seem to be ideal support for initial microsurgical learning. The multiplicity of models described makes it possible to achieve progressive learning depending on which models are available.

Preiser's disease or avascular osteonecrosis of the scaphoid: An updated literature review.

Avascular necrosis of the scaphoid, often referred to as Preiser's disease, is little known despite the scaphoid being the second most frequently involved location in avascular pathology of the carpal bones after the lunate (Kienböck's disease). Nonetheless, very few cases have been reported in the medical literature over the last century. Its pathophysiology is not completely elucidated although the unique vascularization of the scaphoid and several risk factors seem to be recurrently incriminated. Two new classifications based on modern imaging have appeared in the last decade and are now considered essential supplements to Herbert and Lanzetta's original radiographic classification. Because of the lack of formal treatment guidelines, a wide range of different treatments have been explored over time, contributing to the confusion around this pathology. Adding to this confusion, are the numerous terms used to designate the condition and lack of knowledge concerning its pathophysiology, risk factors, clinical and radiographic presentation. The aim of this review is therefore to explore and clarify Preiser's disease in terms of history, terminology, pathophysiology, clinical considerations and imaging and to propose a simple updated treatment algorithm based on the results provided by a thorough review of literature (53 publications, 170 patients) since Georg Preiser's original and controversial description in 1910.

Revision of Arpe® trapeziometacarpal prosthesis by isolated head and linear exchange in five patients.

With the increase in the number of trapeziometacarpal arthroplasties being done, the indications for revision due to implant wear will also increase significantly in the coming years. Isolated linear exchange in the context of polyethylene wear without osteolysis or loosening of the implants is already well known in the case of hip arthroplasty. This revision option offers the advantages of less morbidity, faster recovery, and bone preservation. We retrospectively reviewed five patients who underwent trapeziometacarpal revision with isolated polyethylene liner exchange. Revision surgery was performed an average of 17.6 years (10.7-21.3 years) after the primary arthroplasty procedure. The indication for revision was dislocation in four cases and prophylactic revision for wear and limited osteolysis of the cavity in the other case. Mean follow-up was 48.7 months (36-60). One patient had a recurrent dislocation 4 years after revision and required another revision where only the cup was changed. The other patients had no instability, and no complications were reported. The mean QuickDASH score was 11.9 (4.5-15.9). Pinch strength was 102% (90-120) and grip strength was 92% (70-110) relative to the opposite side. Radiological evaluation showed no abnormalities at the last follow-up. Trapeziectomy is often the solution of choice in the surgical revision of arthroplasties. Unipolar revision of the cup has the risk of trapezium fracture, especially when the cup is well integrated. The technique we report here preserves bone and simplifies the surgical procedure with outcomes corresponding to those of primary arthroplasty. Isolated exchange of the polyethylene liner is a relevant option in the revision of trapeziometacarpal arthroplasty with good short-term results.

Does the repetition over a short time of a microsurgical suture improve its reliability?

Our hypothesis was that immediate repetition of a microsurgery-suturing task will improve its execution and outcome. This was an experimental animal study. Ten surgeons were divided into two groups of five surgeons. Each performed two end-to-end carotid anastomoses on the same rat, one after the other. The anastomosis was evaluated by the surgeon and an instructor. The primary endpoint was permeability. The outcome was evaluated using an objective and subjective assessment grid yielding 1 to 3 points per item. The total scores for each of the 10 surgeons were used to compare the anastomosis of carotid 1 versus 2, using the ratings given by the surgeon and the instructor. Twenty anastomoses were performed, but 1 rat died intraoperatively, leaving 18 anastomoses for evaluation. No significant differences were found on the main endpoint of permeability, with all anastomoses being permeable. The surgeon's self-assessment was significantly better for the second carotid artery (P=0.05), but this was not confirmed by the proxy assessment (instructor). The analysis by subgroups-morning versus afternoon-found the second carotid anastomosis was significant better in the self-assessment and proxy assessment for the morning group (P<0.001, P=0.024). There was no significant difference in clamping times. The immediate repetition of a microsurgical procedure seems to favor its execution, which leads us to propose that the more difficult or important anastomosis should be done after an easier or less important one during complex surgeries. LEVEL OF EVIDENCE: 2B.

Middle phalangectomy with shortening fusion of the fifth finger in Dupuytren's digital hooks.

Severe contracture of the little finger due to Dupuytren's disease continues to be a therapeutic problem. Fifth finger amputation, which is sometimes the only solution, has a major negative impact on function and appearance, and exposes the patient to adjacent digital hook aggravation. Middle phalangectomy with finger shortening fusion is an alternative surgical solution. The aim of this study was to report on a continuous series of 36 cases treated with this approach. This was a retrospective series of 33 patients (26 males and 7 females) operated from 1994 to 2015. All patients had severe contracture of their little finger and 30 had prior surgery. The combined extension lag was 143° (75-270), with considerable functional deficit and poor appearance. The surgical technique consisted of a dorsal approach, a more or less extensive excision of the middle phalanx, and arthrodesis with alignment of the remaining bone segments, while preserving the fingertip/nail complex. The following outcomes were determined when the patients were reviewed: functional discomfort and use, appearance, residual pain, pulp sensitivity, recurrence of contracture and overall satisfaction. Six patients were dead and two were lost to follow-up. Twenty-five patients (27 cases) were reviewed at a mean follow-up of 64 months (12-280). There were no post-operative complications. Twenty-two patients (24 cases) were satisfied or very satisfied. The resulting appearance was graded at 7.13/10 (1-10). Pain on a 10-point Visual Analog Scale was 0.46 (0-5). Cold intolerance was found in 9 cases (33.3%) and decreased fingertip sensitivity in 3 cases (11.1%). The hand could be flattened in 21 cases; in the other cases, it could not be flattened due to contracture in another finger. Wearing gloves was again possible in 26 cases. Fusion was achieved in 18 of the 21 cases evaluated with X-rays at the last follow-up (85.7%). All the other cases had a non-union with no clinical repercussions. There were 5 local recurrences at the level of the little finger. Finger shortening through a dorsal approach seems to provide satisfactory outcomes in patients with Dupuytren's disease who have severe contracture of the little finger. This technique results in an acceptable looking functional finger, which has sensation and no significant morbidity.

Primary flexor tendons repair in zone 2: Current trends with GEMMSOR survey results.

The repair of flexor tendon lesions in zone 2 remains a highly controversial subject in hand surgery. Currently, there is no consensus about the management of these lesions intra- and postoperatively, but the literature suggests that a solid suture will allow early active motion. We hypothesized that the management of flexor tendon injury in zone 2 varies widely. Two online surveys were conducted with surgeons and hand therapists. The questions captured the demographics of the surveyed population, surgical technique, common complications, postoperative management (duration of immobilization, type of splint, rehabilitation techniques and principles of self-rehabilitation). The responses were compared to current literature data. We collected 366 responses to the "surgery" survey and 206 responses to "rehabilitation" survey. Most surgeons performed suture repair with at least 4 strands (75.9%). Active rehabilitation protocols were used in 48.9% of cases. The "rehabilitation" survey underlined the lack of information provided to therapists by surgeons. Therapists used active protocols in 79.7% of cases. This study found a large variation in the management of flexor tendon injuries, which is not always consistent with current published recommendations. Ideally, the suture repair should be a 4-strand pattern with an epitendinous circumferential suture and a release of the pulley in the suture area. Mobilization and rehabilitation should be started on the 3rd day using an active protocol.

Peritrapezial osteoarthritis: Inter- and intraobserver reliability of the Allieu classification.

The Allieu classification takes into consideration the distal and proximal joints of the trapezium. Trapeziometacarpal (TMC) joint arthritis, TMC joint instability (TMI) and scapho-trapezio-trapezoid (STT) joint arthritis are considered independently, which better corresponds to the anatomical examinations. The aim of the study was to evaluate the inter- and intraobserver reliability of the Allieu classification of the peritrapezial arthritis. This was a prospective, single-center study performed from May to September 2016 with 30 cases of primary thumb osteoarthritis. Five raters scored the X-rays twice. In the Allieu classification, TMC arthritis is scored as "0" when the TMC joint is normal, "1" when the TMC joint space is <50% narrowed, "2" when the TMC joint space is >50% narrowed, "3" when the joint space is loose with advanced degenerative changes. TMI is scored as "0" for reducible subluxation, painful and unstable joint, "1" for advanced reducible subluxation, "2" for chronic subluxation <1/3 of the surface, "3" for chronic subluxation >1/3 of the surface. STT joint arthritis is scored as "0" for normal joint space, "1" for joint space narrowing <50%, "2" for important joint space narrowing and "3" for advanced degenerative changes with sclerotic subchondral bone changes. Inter- and intraobserver reliability was assessed using the weighted Cohen's kappa coefficient. Additional analyses were undertaken to determine the intraclass correlation coefficient (ICC) for the overall raters. The interobserver reliability was "moderate" to "substantial" for the TMC arthritis; "fair" to "substantial" for STT arthritis and "fair" to "substantial" for TMI. The intraobserver reliability was "moderate" to "excellent" for TMC arthritis (2 "excellent", 2 "substantial", 1 "moderate"); "fair" to "excellent" for the STT (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair") and "fair" to "excellent" for the TMI (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair"). The worst reliability, either for intra- or interobserver, was for TMI. The ICC for TMC arthritis was 0.67 (95%CI, 0.28-0.83); for STT it was 0.47 (95%CI, 0.15-0.66) and for TMI it was 0.30 (95%CI, 0.23-0.70), which is "fair". This study confirms a large variation in X-ray staging for peritrapezial arthritis. It shows that the Allieu classification is moderately reliable. However, the interobserver reliability was better for evaluating the TMC than the STT and worse for TMI. The classification for TMC and STT is simple to apply, based principally on the joint narrowing. The intraobserver is better than the interobserver reliability.

Acute finger-tip infection: Management and treatment. A 103-case series.

INTRODUCTION: Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation. MATERIALS AND METHOD: One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16). RESULTS: Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth. DISCUSSION: Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.

Interest of the "compress test" in diagnosis of nerve injury in hand wounds.

INTRODUCTION: Hand wounds are a common cause of emergency department admission. Digital nerve lesions are found in 5% of palm wounds. Early diagnosis reduces the risk of morbidity, sequelae and litigation. Screening for digital nerve injury by the usual tests is difficult in an emergency context. We assessed the diagnostic value of the simple "compress test" to screen for pulp sensibility disorder and the factors that may influence the value of this examination, with a view to validating routine use. MATERIAL AND METHOD: A retrospective study included 821 palm wounds treated between January 2014 and May 2016. There were 605 male and 216 patients; mean age, 42.8 years (range: 18-90 years). The dominant hand was involved in 307 cases (37.4%). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the compress test were calculated. Diagnostic value was also calculated according to age, gender, affected digit, dominant side and examiner's experience. RESULTS: Clinical deficit was found in 412 cases (50.2%). A digital nerve lesion was found intraoperatively in 277 cases (33.6%). Test sensitivity was 87.3%, specificity 68.6%, positive predictive value 58.5%, negative predictive value 91.4%, positive likelihood ratio 2.78 and negative likelihood ratio 0.18. The test was more effective for thumb wounds and for examination by a junior surgeon. There were no differences according to injured side, innervation territory or gender. CONCLUSION: This clinical test is reliable, with very good negative predictive value and good sensitivity, allowing its use in routine clinical practice. Nevertheless, surgical exploration of deep palm injuries should remain the rule.

Cross-finger flap for reconstruction of fingertip amputations: Long-term results.

UNLABELLED: Fingertip amputations are severe hand injuries. Their treatment must restore the sensation and metabolic activity needed for pain-free finger function. The cross-finger flap (CFF) can be used for this purpose. The goal of this study was to assess the long-term clinical outcome following use of this flap. METHODS: This was a retrospective analysis of 28 patients operated because of fingertip amputation: 16 type 3, 8 type 2 and 4 type 4. The CFF was harvested from an adjacent finger on the dorsal side of the middle phalanx down to the epitenon. A dorsopalmar hinge was preserved to ensure vascularisation. The CFF was divided an average of 18.7 days later. The following parameters were evaluated: pulp volume (injured compared to contralateral finger), presence of neuroma, occurrence of complications (necrosis, infection, and donor site morbidity), cold discomfort, static and tactile discrimination, and patient satisfaction (0 to 10 on VAS). RESULTS: The average follow-up was 19.7 years; 22 patients (78.6%) were re-examined in person or contacted by telephone. The average healthy pulp to reconstructed pulp ratio was 1.03. No postoperative complications such as neuroma were found. Cold sensitivity was present in 7 patients. The flap was re-sensitised in all the patients. There was no donor site morbidity. The average patient satisfaction score was 9 (range 8-10). CONCLUSIONS: Over the long-term, use of the CFF results in nearly normal fingertip metabolism, no complications and good distal sensitivity without pain or neuromas. This is a simple, reliable, long-lasting reconstruction technique. LEVEL OF EVIDENCE: IV.

Intermediate term evaluation of the Eclypse distal radio-ulnar prosthesis for rheumatoid arthritis. A report of five cases.

HYPOTHESIS: Early medical management of rheumatoid arthritis with biotherapy has changed the traditional musculoskeletal damage from this disease. When the distal radio-ulnar joint (DRUJ) is involved, classic procedures may be inappropriate. We chose a hemi-arthroplasty of the DRUJ joint (Eclypse™) in patients with persistent synovitis and chondrolysis with a stable joint. The aim of this study was to assess the intermediate term results of this approach in these specific cases. MATERIALS AND METHODS: We report a retrospective study of 5 Eclypse arthropasties implanted between March 2005 and March 2011. There were 4 women and 1 man, mean age: 58.4years old (54-62) with RA that had been present for 21.6years (15-33). This hemi-arthroplasty replaced the ulnar head with a pyrocarbon component. Patients were evaluated by an independent observer for pain by VAS, range of motion, grip strength in the neutral position by Jamar dynamometer, pronation and supination strengths with a pronosupinator, DASH score and wrist X-rays. RESULTS: One patient was lost to follow-up and the 4 others underwent a follow-up evaluation at 64 months (43-90). There were no intra-operative or postoperative complications. The pain score at the final follow-up was 1.5/10 (0-4), pronation was 70° (60-80) and supination was 80° (80-80). Grip strength was 148% compared to the contralateral side (73-200%). Pronation and supination strengths were 1.7kg (1.5-2) and 2.1kg (2-2.5) respectively. The DASH score was 55.9 points (42.6 to 79.3). X-rays did not show any changes in the ulnar notch. CONCLUSION: This distal radio-ulnar arthroplasty is less invasive and preserves the bone and ligaments. Clinical results are rapid, remain stable over time and are well tolerated. This arthroplasty, which was initially developed for osteoarthritis and traumatic lesions of the DRUJ, is promising for specific cases of rheumatoid arthritis.

"Butterfly flap": The retinaculum to the rescue of the extensors.

Extensor digitorum tendon (EDT) tear in the wrist is frequently associated with inflammation (rheumatoid arthritis, chondrocalcinosis) or distal radio-ulnar osteoarthritis. EDT protection and repair is often hampered by poor tissue trophicity and associated procedures. We describe an extensor retinaculum (ER) plasty, protecting and recentering the EDTs. The procedure consists in raising the ER on either side of Lister's tubercle so as to create a strap protecting and recentering the 4th, 5th and 6th compartment EDTs; the 2nd and 3rd compartment EDTs are left free on the lateral side of Lister's tubercle. This "butterfly plasty" provides solid and effective protection of the EDTs in an often fragile pathologic context. It creates a glide space, stabilizing EDTs and wrist. LEVEL IV: Retrospective series.

Predictive factors of scapular notching in patients with reverse shoulder arthroplasty.

INTRODUCTION: The main complication of reverse shoulder arthroplasty is the development of notches in the scapular pillar, which occurs in 44% to 100% of cases. Furthermore the functional score has been shown to be poorer in patients with high-grade notches. Many options have been proposed to reduce this risk. The purpose of this study was to evaluate the predictive factors of the development of scapular notches. MATERIALS AND METHODS: We retrospectively evaluated 133 shoulders in 121 patients with reverse shoulder arthroplasty. We performed a radiographic assessment of the effect of positioning the glenoid component with inferior overhang of the glenosphere and the glenometaphyseal angle. All patients were reviewed after 2years follow-up, including a clinical assessment based on the Constant score and X-rays to assess the presence of notches. RESULTS: Nineteen complications were reported, and 14 required revision surgery. We excluded patients in whom prosthetic components were changed. The quality of the X-rays was not satisfactory enough to be analyzed in over 15 patients so they were excluded. One hundred five patients were reviewed. At 2years follow-up, 50.4% of shoulders presented with notches. The Constant score was 69.3 points (54-83) in shoulders without notches, and 66.4 points (38-82) in shoulders with notches. The average glenosphere overhang was 3.5mm (-1 - 8mm). Notches were present in 65.5% if it was less than 3mm and 39.6% if it was more than 2mm (P<0. 05). The average glenometaphyseal angle was 27.3° (4-59°), and notches developed in 72.2% if it was more than 28° and 26.5% if it was less than 28° (P<0.05). CONCLUSION: The position of the metaglene influences the development of notches. The risk decreases if the glenosphere overhangs the glenoid. The degree of adduction of the arm influences the development of notches and can be correlated with the patient's BMI. LEVEL OF EVIDENCE: Level IV retrospective study.

Neuroma-in-continuity of the median nerve managed by nerve expansion and direct suture with vein conduit.

Autologous nerve grafting is the current standard for bridging large gaps in major sensory and motor nerves. It allows both function and pain improvement with predictable results. Clinical observations of nerve elongation caused by tumours have prompted experimental animal studies of induced gradual elongation of the nerve stump proximal to the gap. This technique allows direct suturing of the two nerve ends to bridge the gap. Here, we describe a case of neuroma-in-continuity of the median nerve managed by resection and direct suture after nerve elongation with a tissue expander. We are not aware of similar reported cases. Secondary repair 3 years after the initial injury improved the pain and hypersensitivity and restored a modest degree of protective sensory function (grade S1).

[Treatment for a chronic proximal interphalangeal fracture-dislocation with hemi-hamate arthroplasty]. / Traitement d'une fracture-luxation chronique de l'interphalangienne proximale par un greffon d'hémi-hamatum.

Fracture-dislocations of the proximal interphalangeal (PIP) joint are complex and challenging to manage once they become chronic. We report a case of PIP joint fracture-dislocation treated by hemi-hamate arthroplasty. An 18-year-old male polytrauma patient presented with a neglected PIP joint fracture-dislocation in the third finger of the left hand. After four months of follow-up, he remained disabled due to clinodactyly and stiffness. After performing a cadaver study to evaluate the feasibility of grafting, we resurfaced the bone-cartilage defect with a hemi-hamate arthroplasty. The range of motion at the last follow-up was 65° without pain; the DASH score was 2.27. The patient was able to return to heavy manual labour work at 5 months postoperative.

Is radiographic measurement of distal femoral torsion reliable?

BACKGROUND: Distal femur torsion (DFT) is a crucial parameter in knee replacement surgery. The reference standard for measuring DFT is posterior condylar angle (PCA) measurement using computed tomography (CT). The objective of this study was to assess the feasibility and reliability of a radiographic PCA measurement method. MATERIALS AND METHODS: We studied 125 osteoarthritic knees in 79 patients (42 women and 37 men) with a mean age of 71.6 ± 8.8 years (range 47 to 86 years); 32 knees were aligned, 85 in varus, and eight in valgus. DFT was measured on an antero-posterior (AP) radiograph of the knee in 90° of flexion (known as the seated AP view). The PCA was defined as the angle subtended by the tangent to the posterior condyles and the transepicondylar axis (anatomic PCA [aPCA]) or the line connecting the lateral epicondyle to the medial sulcus (surgical PCA [sPCA]). The PCA was conventionally recorded as positive in the event of external torsion and negative in the event of internal torsion. PCA measurements were performed three times by each of five observers to allow assessments of inter-observer and test-retest reliabilities. RESULTS: aPCA was consistently negative (mean, -6.1 ± 1.6°) (range, 0 to -10°); inter-observer and test-retest reliability were satisfactory (0.54

Internal fixation of complex fractures of the tarsal navicular with locking plates. A report of 10 cases.

INTRODUCTION: Tarsal navicular fractures are rare and treatment of comminuted fractures is especially difficult. Since 2007, the authors have had access to 3D reconstruction from CT scan images and specific locking plates, and they decided to evaluate whether these elements improved management of these severe cases. MATERIALS AND METHODS: Between 2007 and 2011, 10 comminuted tarsal navicular fractures were treated in a prospective study. All of the fractures were evaluated by 3D reconstruction from CT scan images, with suppression of the posterior tarsal bones. The surgical approach was chosen according to the type of lesion. Reduction was achieved with a mini-distractor when necessary, and stabilized by AO locking plate fixation (Synthes™). Patient follow-up included a clinical and radiological evaluation (Maryland Foot score, AOFAS score). Eight patients underwent postoperative CT scan. RESULTS: All patients were followed up after a mean 20.5 months. Union was obtained in all patients and arthrodesis was not necessary in any of them. The mean Maryland Foot score was 92.8/100, and the AOFAS score 90.6/100. One patient with an associated comminuted calcaneal fracture had minimal sequella from a compartment syndrome of the foot. DISCUSSION: The authors did not find any series in the literature that reported evaluating tarsal navicular fractures by 3D reconstruction from CT scan images. The images obtained after suppression of the posterior tarsal bones systematically showed a lateral plantar fragment attached to the plantar calcaneonavicular ligament, which is essential for stability, and which helped determine the reduction technique. Locking plate fixation of these fractures has never been reported. CONCLUSION: Comminuted fractures of the tarsal navicular were successfully treated with specific imaging techniques in particular 3D reconstructions of CT scan images to choose the surgical approach and the reduction technique. Locking plate fixation of the navicular seems to be a satisfactory solution for the treatment of these particularly difficult fractures. LEVEL OF EVIDENCE: Level IV.

Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: is outcome influenced by the occupational disease compensation aspect?

INTRODUCTION: The etiology, treatment, and patient management in cases of chronic epicondylitis, within the legislation on occupational disease, remain highly controversial. HYPOTHESIS: Recognition as an occupational disease has a negative influence on the functional result of epicondylitis treated with aponeurotomy and neurolysis of the motor branch of the radial nerve. PATIENTS AND METHODS: Twenty-eight patients (30 cases of epicondylitis) were operated between January 2007 and January 2008. There were nine men and 19 women whose mean age was 46.1 years. A preoperative EMG found anomalies in the deep posterior interosseous nerve in all cases. Patients were divided into two groups: one group of patients recognized as having an occupational disease and a group of patients whose disease was not considered occupation-related. RESULTS: The patients were seen at follow-up at a mean 21.8 months. In the group of patients with occupational disease, there were six excellent, nine good, and five acceptable results; in the second group, there were six excellent, two good, and two acceptable results. CONCLUSION: Recognition of epicondylitis as an occupational disease has a significant influence only on the time to pain relief and the result on strength. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.