[Analgesia in surgery of the foot. Apropos of 1373 patients]. / L'analgésie dans la chirurgie du pied. A propos de 1373 patients.

This retrospective study concerns 1,373 adult patients who underwent forefoot surgery during 1988-95 under regional anaesthesia by ankle nerve blocks (of posterior tibial nerve systematically and other nerves according to the surgical site). As a rule, plain bupivacaine 0.5% (maximum 40 mL) was used, completed if necessary by lidocaine 1% (a few mL). A nerve stimulator is currently used for posterior tibial blocks. About 50% of indications (such as hallux surgery) require short hospitalization (3 days). A catheter is inserted near to the posterior tibial nerve by the surgeon, allowing postoperative reinjections of 10 mL of bupivacaine 0.25% every 6 hrs by nurses, for 1-2.5 days. Other patients undergoing minor procedures (material removal, cysts, exostosis, etc.) can be operated on a day-care basis, without postoperative analgesic injections. Results were very satisfactory for both patients and surgeons. No general anaesthesia was needed (except after one case of convulsions, likely from accidental injection of a few mL of local anaesthetic and without any sequelae). Five patients complained of temporary paraesthesias, with indication of a posterior tibial neurolysis in one case and complete recovery. Thus ankle blocks appear increasingly to be a satisfactory alternative to general anaesthesia for most surgical procedures on the forefoot, provided that all usual safety conditions are respected and the patient's acceptance of the procedure is obtained.

[Anaphylactic shock after tourniquet removal in orthopedic surgery]. / Chocs anaphylactiques après levée de garrot en chirurgie orthopédique.

Case report of six patients who experienced symptoms of severe anaphylactic shock, after tourniquet release at the end of minor orthopaedic surgery of the limbs under regional anaesthesia. The immunological mechanism of the shock was confirmed by prick tests. The causative agent was rifamycin SV used for cleaning the surgical wound prior to its closure. In case of repetitive surgery and/or in allergic patients the use of another antibiotic or the simple cleaning of the wound with normal saline should be considered. In case of surgery using a tourniquet, an iv access should be maintained for 1 hour after tourniquet release and the patient closely monitored in the recovery room. The allergologic assessment should take place 3 to 6 weeks later and include all drugs administered during the 10 minutes preceding the occurrence of shock.

[Effect of ornithine oxoglutarate on the duration and quality of wound healing in extensive reparative and plastic surgical methods]. / Incidence de l'oxoglutarate d'ornithine sur la durée et la qualité de la cicatrisation au cours des grands décollements de la chirurgie réparatrice et plastique.

Fifty-two overweight female patients hospitalized for a major plastic surgical procedure were included in a therapeutic trial designed to evaluate wound healing. Twenty-seven patients were randomized to a placebo and 25 to ornithine oxoglutarate (Cetornan). There were no statistical differences between patients concerning age, type of plasty, extent of detachment, or overall evaluation of physical condition at the time of randomisation. Evaluation was based mainly on clinical criteria, including duration and quality of healing, and type of complications. Results showed a significant improvement in time to healing in the Cetornan group (18 +/- 1 day) as compared to the placebo group (26 +/- 3 days) (p less than 0.01). Complications occurred in nine of the 27 patients under placebo (30%) and in three of the 25 patients under Cetornan (12%) (p = 0.07). Clinical and biological tolerance was outstanding. No patient was excluded during the trial.

Thumb reconstruction pollicisation or toe-to-hand transfers. A comparative study of functional results.

A statistical study of thumb reconstruction after traumatic amputation, based on the records of 33 pollicisations and 21 microsurgical toe-to-hand transfers was made. A precise method of evaluation of results is presented. The types of lesions are divided into 4 groups; 1: amputation of the thumb without injuries of the other fingers; 2: amputation of the thumb associated with amputations or mutilation of other fingers; 3: metacarpal hand; 4: amputation of the thumb distal to the metacarpophalangeal joint. The aim of this study was to determine the respective indications of the two methods. It may be concluded that: in group 1, the results of pollicisation and of toe-to-hand transfers are similar. The former is superior as far as the discriminative sensory and fine motor results are concerned, while toe transfer reestablishes better strength. In group 2, the more the other fingers are mutilated, the more toe transfers should be preferred to pollicisation which weakens the performance of the long fingers, especially when they are injured. In group 3 (metacarpal hand), the transfer of one or more toes is a revolution. It is the only technique capable of returning function and, if technique is correct, a cosmetically satisfactory aspect as well. In distal amputations of the thumb (group 4), the only indications for pollicisation are cases of a proximally injured finger with a healthy distal segment, transferable on healthy pedicles, which is relatively rare. Partial toe-to-hand transfers, is a new solution to this challenge.

Functional comparison between pollicization and toe-to-hand transfer for thumb reconstruction.

The functional results of two methods of thumb reconstruction, pollicization, and toe transplantation were evaluated in four groups of patients: Group I, those missing the thumb but with four other normal digits; Group II, those missing the thumb with partially mutilated or amputated other digits; Group III, those with a metacarpal hand; and Group IV, those with a distal thumb amputation. In each group, results were compared in six categories: mobility, strength, sensibility, cosmetic appearance, pinch accuracy, and grasping power. In Group I, pollicization provided superior sensibility and mobility, but grasping power was best achieved by transfer of the big toe. Second toe transfer and pollicization both resulted in some weakness, compared with the normal hand. Pinch accuracy, related to the quality of sensibility, was better achieved by pollicization than by any free transfer. In Group II, although pollicization of a mutilated digit is more controversial, a very good functional level was reached in some cases, directly related to the amount of preoperative sensibility and the mobility of the proximal interphalangeal joint in the transferred digit. Reduction of strength and prehension depended on the number and quality of the remaining nontransferred digits. Toe transfer yielded better results in all six categories, as the severity of digit mutilation increased. In Group III, pollicization of the second metacarpal achieved a very rudimentary pinch, with toe transfer allowing for much greater prehension possibilities. In Group IV, distal thumb amputations were treated with distal digital pollicization as well as with partial toe transplantation. Both methods did well; however, indications for pollicization were extremely limited. Comparing results of big and second toe transfer for thumb reconstruction, big toe transfer achieved superior results, in both functional and cosmetic aspects.

[Malunions of the metacarpals and phalanges. Results of surgical treatment]. / Les cals vicieux des métacarpiens et des phalanges. Résultats du traitement chirurgical.

The authors have made an analysis of the results obtained after surgical correction of 30 malunited metacarpals and phalanges. Nine involved joints, but the remainder did not. In 25 cases, there was limited movement associated with the malunion. The surgical devices were specially designed for surgical treatment and the technique employed is described. It is concluded that the correction of malunion needs to be made but that this alone is not sufficient to obtain a satisfactory result. The effectiveness of added tenolysis, arthrolysis, post-operative bracing and rehabilitation is even more important. The indications for treatment are given according to the level and location of the malunion.