Double Oblique Osteotomy and Rotation of the trapeziometacarpal Joint (DOOR procedure).

The double oblique osteotomy with rotation of the trapeziometacarpal (TMC) joint procedure (DOOR procedure) is a surgical technique conceived to treat non-traumatic TMC instability, often responsible for TMC joint osteoarthritis. The main goal of this procedure is to correct the exaggerated slope of the trapezium. It also allows opening of the first web space, transfers pressure to healthy cartilage areas, and reverses the forces exerted on the trapeziometacarpal ligaments. The technique is demanding and should be learned in the anatomy laboratory. Since 2000, we have carried out 96 cases, evidence that this technique is reliable. Our case series consists of 88 patients (71 females, 17 males), with 8 patients operated bilaterally. The average age at the time of the procedure was 48 years. The first 22 operated (24 cases) between 2000 and 2005 were reviewed in 2015 with an average follow-up of 13 years. Pain averaged 0.5 on VAS. The average QuickDASH score was 6. The average mobility according to Kapandji's index was 9 for opposition and 3 for retropulsion. The grip strength compared to that of the contralateral side was 180%, the key pinch strength was 100% of the contralateral side and the tip pinch strength was 98%. This intervention makes up approximately 10% of our surgical indications in thumb basal joint arthritis. It is reserved for young women with early arthritis or unstable thumbs, and for men who perform manual labor. While the results take a long time to achieve (about 3 months), they remain highly satisfactory at the average follow-up of 13 years.

[Radiocarpal reconstruction by island transfer of the distal radio-ulnar joint]. / Reconstruction radiocarpienne par transfert en îlot de l'articulation radio-ulnaire distale.

INTRODUCTION: We described the island transfer of the DRUJ to reconstruct the radiocarpal joint when the radiocarpal and the mediocarpal joints are destroyed. The objective is to avoid wrist arthrodesis or prosthesis. PATIENTS AND METHOD: From 1993 to 1997, five patients were operated, five men, the average age was 55 years (36 to 67). The operated side was the dominant side one time. The joint destruction was secondary to: SLAC wrist (stage 3) in two cases, a failure of PRC in two cases and post-traumatic necrosis of the lunatum in one case. RESULTS: One failure was resumed by total wrist arthrodesis at 1-year follow-up. Four patients were revised with 11 years follow-up (from nine to 13). Two patients presented a pain-free wrist, two patients complain of barometric pain or after heavy works. The average mobility was: extension 40°, flexion 25°, ulnar deviation 30°, radial deviation -3°, complete pronosupination. The strength was 65% of the opposite side. X-rays showed an important radiocarpal reshaping and ulnar sliding of the carpus. DISCUSSION: The island transfer of the DRUJ was possible in every case. The discordance between clinical and radiological results can be explained by joint denervation. We stopped this procedure not to sacrifice any more the healthy DRUJ. CONCLUSION: The island transfer of the DRUJ to reconstruct the radiocarpal joint is a solution to avoid total wrist arthrodesis or prosthesis if we accept the DRUJ sacrifice.

[Early stages of trapezo-metacarpal joint arthritis and rotatory island transfer of the trapezo-metacarpal joint. DOOR procedure]. / Rhizarthrose débutante et rotation du bloc articulaire trapézométacarpien en îlot sur le pédicule radial. DOOR procedure.

INTRODUCTION: Trapezium dysplasia and trapezo-metacarpal joint instability induce TMC-joint arthritis. To correct these two factors, we propose a surgical technique associating a double oblique osteotomy of the trapezium and of the first metacarpal basis, and an island rotator transfer of the TMC-joint harvested in block on the radial pedicle. The articular block is rotated at 180° on the longitudinal axis of the thumb. METHOD: Since 2000, 41 cases were performed on 38 patients (35 women, three men). Mean age was 47 (from 17 to 63). All the patients complained of a painful thumb and sometimes of instability. The mobility was preserved (Kapandji 9/3). The grasp was 43% of the opposite side. X-rays showed a TMC-joint instability in all the cases. RESULTS: DOOR procedure was possible 41 times. With a mean follow-up of 65 months (from three months to ten years), 28 thumbs are pain-free, nine patients complain of barometric pain or pain after heavy works. Four thumbs were reoperated after failure of the procedure. Mobility decreased (Kapandji 8/2), the grasp increased to 100% of the opposite side. The joint was stabilized in all the cases. X-rays showed an osteolysis in three cases. The cartilage was worse in 19 cases, improved in five cases, stable in 14 cases. DISCUSSION: DOOR procedure is a very demanding procedure but reliable. The correction of the dysplasia is constant. Denervation could explain the good clinical results in cases of joint narrowing. CONCLUSION: DOOR procedure is a solution in cases of trapezium dysplasia associated with instability and early stages of osteoarthritis in young women.

[Replacement and resurfacing prosthesis of the distal radius: a new therapeutic concept]. / La prothèse de remplacement et resurfaçage du radius distal: un nouveau concept thérapeutique.

Complex intra-articular distal radius fractures represent a challenging therapeutic problem. We propose in these difficult cases to replace and to resurface the distal radius by a prosthesis, especially in fractures related to aging and osteoporosis. We have designed an anatomic prosthesis to replace and resurface the distal radius. The design was obtained from radiographs, tomograms and anatomical specimens. The prosthesis is composed of a radial stem and an epiphyseal-metaphyseal bloc articulating both with the carpal condyle and the ulnar head. The epiphyseal-metaphyseal bloc can rotate 10 degrees on the longitudinal axis of the stem. From March 2005 to February 2007, six patients were operated on: five women and one man, the mean age was 73 years (38-87). Five cases were elderly and osteoporotic patients: four had complex intra-articular fractures and one had a malunion complicated by extensor tendon ruptures. In one case, the procedure was performed on a young man with a pathologic fracture (giant cell tumor). The patients were reviewed with a mean follow-up of 27 months (13-36 months). Five patients are satisfied or very satisfied but one patient is dissatisfied due to a stiff wrist after an algodystrophic syndrome. The mean mobilities are: extension 65 degrees, flexion 30 degrees, ulnar inclination 20 degrees, radial inclination 20 degrees, pronation 60 degrees, supination 50 degrees. The mean strength was 80% of the contralateral side. The implants are perfectly stable on the radiographs. Replacement and resurfacing of the distal radius by a prosthesis articulating both with the carpal condyle and ulnar head is possible. The preliminary clinical results are good. This prosthesis takes into account the transmission of the pronosupinator couples through the wrist. The longitudinal rotation between the stem and the epiphyseal-metaphyseal bloc has three goals: the first is to decrease the constraints born from the pronosupination torques, the second is to improve the congruence with the carpal condyle, the third is to increase radio-ulnocarpal stability. The treatment of complex intra-articular distal radius fractures by replacement and resurfacing prosthesis is a solution we can now consider in elderly patients with osteoporosis. This solution seems ideal for distal radius tumors.

[Trapezo-metacarpal arthroplasty by rotation transfer of the trapezo-metacarpal joint. Anatomical study and operative technique]. / Arthroplastie trapézo-métacarpienne par rotation trapézo-métacarpienne en îlot. Etude anatomique et technique opératoire.

INTRODUCTION: To correct trapezium dysplasia we propose a new surgical technique. The operation consists of a double osteotomy of the trapezium and of the first metacarpal base, thereby harvesting the trapezo-metacarpal joint en-bloc. Vascularization is via the radial artery pedicle divided at the first web level. The articular block is then rotated 180 degrees on the longitudinal axis of the thumb. METHOD: An anatomic study was performed on six fresh cadaveric upper limbs. The radial artery was injected with colored latex, 5 cm above the wrist. The peri-articular vascular network was studied. The feasibility of harvesting and rotating the articular bloc after double osteotomy of the first metacarpal basis and the trapezium was also studied. RESULTS: In all the cases, the radial artery was present with branches supplying the peri-articular vascular network. After double osteotomy of the metacarpal base and of the trapezium, the articular bloc was harvested and rotated by 180 degrees. We describe the surgical technique. DISCUSSION AND CONCLUSION: The surgical technique has been confirmed with the first clinical cases. The double oblique osteotomy with rotation of the articular bloc corrects trapezium dysplasia and preserves first metacarpal abduction. This procedure appears to be a solution in cases of trapezium dysplasia associated with instability and early stage osteoarthritis.

[Vascularized bone transfers in the wrist and hand]. / Les transferts osseux vascularisés au poignet et à la main.

More and more vascularised bone transfer (VBT) sites, free or pedicled, in the wrist and hand have been described since the 1980s. In the distal forearm, two main VBT: the fibula and the iliac crest, are used for large bone loss (> 6 cm) or for radio-carpal reconstruction. We report our experience of radio-carpal reconstruction using the distal-radio-ulnar joint transfer. At the carpal level, VBT are essentially used for "difficult" scaphoid pseudarthrosis: osteonecrosis, sclerotic bone or failures of conventional grafts and for lunate necrosis. Two pedicled VBT are frequently used for the scaphoid, a graft harvested from the antero-medial part of the distal radius (Kuhlmann) or a graft harvested from the postero-lateral part of the distal radius (Zaidemberg). For the trapezo-metacarpal joint, two new articular pedicle transfers can be used in some cases of trapezo-metacarpal arthritis. At the hand level, VBT are used for distal bone loss, "en bout de chaîne". Bone vascularisation is indispensable to preserve sub-chondral bone and avoid articular destruction. In children VBT are necessary to preserve the growth cartilage.

[Linburg-Comstock syndrome. Epidemiologic and anatomic study, clinical applications]. / Syndrome de Linburg-Comstock. Etude épidémiologique et anatomique, application clinique.

The Linburg-Comstock (LC) syndrome is distinguished by the inability to actively flex the interphalangeal (IP) joint of the thumb without simultaneously flexing the distal IP joint of the index finger. Any resistance to this 'parasitic' reaction causes pain on the palmar side of the wrist or in the distal part of the forearm; this is due to an anomalous tendinous connection between the flexor pollicus longus (FPL) and the flexor digitorum profundus (FDP). An epidemiological study was carried out on 264 individuals (a total of 528 hands were examined), and the LC syndrome was found in 98 subjects (37%); women were more frequently affected than men, and bilaterally rather than unilaterally. In addition, we dissected 26 fresh cadaver upper limbs, and in seven cases found an anomalous connection between FPL and FDP. We also examined the case of a young violinist with bilateral LC syndrome, who complained of pain in the distal part of the left forearm after prolonged musical exercises. Surgical investigation determined a complete fusion between FPL and FDP of the index with a common tendon. Treatment consisted of splitting this common tendon to form two separate tendons, thereby permitting a certain degree of independence between the thumb and index finger, and which considerably improved the violinist's musical performance. A review of the literature showed that there was a large quantity of anatomical descriptions available on these types of connection. Certain publications also provide an extremely precise report on the anthropological significance of these anomalies.

[Anatomical study of interosseous flaps and the concept of postero-anterior interosseous flap. Preliminary report]. / Etude anatomique des lambeaux interosseux et concept de lambeau interosseux postéro-antérieur. Rapport préliminaire.

The postero-anterior interosseous flap uses the distal network of the posterior and anterior interosseous arteries. With this flap the authors would like to point out all the possibilities of reverse fascio-cutaneous flaps offered by the interosseus arteries. An anatomic study has been carried out with both a literature review and a cadaveric study. The authors studied the distal interosseous anatomy on 40 fresh upper arms after colored latex injection of the anterior interosseous artery near its origin. A distal anastomosis between anterior and posterior interosseous arteries was present in 38 cases. This anastomosis was situated at an average of 25 mm from the radio-carpal joint. The authors found the fascio-cutaneous artery branch of the anterior interosseous flap in 40 cases, but its origin is variable. Therefore, the anterior interosseous flap was possible in every case but the pedicle length was variable. The surgical technique must begin by a distal exploration of the vascular network. After this exploration the flap is chosen in function with the anatomic possibilities and the cutaneous defect. The authors have already used several kinds of reverse interosseous flap: anterior (6 cases), posterior (11 cases) and recently, postero-anterior (2 cases). With the postero-anterior flap the authors will show the large range of flap possibilities offered by the interosseous arteries for the cutaneous defects of the dorsum of the hand.

[Arthroplasty of the wrist by island transfer of the inferior radio-ulnar joint]. / Arthroplastie du poignet par transfert en îlot de l'articulation radio-cubitale inférieure.

In cases of advanced osteoarthritis of the wrist, in which the radiocarpal and midcarpal joint spaces have been destroyed, the authors propose island transfer of the distal radioulnar joint. They studied the blood supply of the distal radioulnar joint from the interosseous arteries on 40 fresh cadaver upper limbs. The anatomical study showed that the dorsal epiphyseal periosteal network was supplied by the lower perforator of the anterior interosseus artery in every case and by the posterior interosseous artery in 38 out of 40 cases. The distal radioulnar joint can be harvested "en bloc" and rotated 90 degrees so that the joint space can be placed in radio-carpal position while preserving its blood supply on the anterior interosseous pedicle. The authors describe their operating technique and present their first clinical case. This new operation represents a non prosthetic alternative to arthrodesis.

[Transmission of pronation-supination movements in the wrist]. / Etude de la transmission des mouvements de pronosupination au niveau du poignet.

The wrist plays an essential in role the transmission of pronosupination movements. The four main muscles responsible for these movements are situated above the radiocarpal joint. This anatomic configuration allows a passive movement: Radio Metacarpal Rotation or RMR which is analysed here. Radio Metacarpal Rotation varies according to grip and the couple which is applied distally. An apparatus has been designed to simultaneously measure the angle, the force of grip and the couple. Radio Metacarpal Rotation is firstly measured with the wrist relaxed (grip strength < 5 N) and a distally applied rotation couple of 0.2 N.m in the supination direction and 0.5 N.m in the pronation direction. Secondly, the patient is asked to maintain a grip strength between 80 N and 100 N, and a couple of 1 N.m is applied distally in each direction. One hundred wrists were evaluated. We have looked for the rotation centers of active pronosupination and Radio Metacarpal Rotation. A three dimensional motion analysis device was used (ELITE system). Thirty normal wrists were evaluated. An anatomic study of the radiocarpal ligaments stretched by Radio Metacarpal Rotation was carried out on ten cadaver wrists. When the wrist is relaxed: there is an average Radio Metacarpal Rotation of 42 degrees. This Radio Metacarpal Rotation is reduced when grip is tightened. We have defined a locking test based on these two parameters. This clinical test is represented by two curves on a graph. The active pronosupination center and the radio metacarpal center do not coincide. The center of active pronosupination is situated near the center of the ulnar head and the center of radio-metacarpal rotation is always more lateral. On the anatomical preparations, we found a helicoidal configuration of the radiocarpal ligaments: a ligamentous double helix pronosupination. Radio Metacarpal Rotation interferes with transmission of pronosupination movements. When the wrist is not well locked there is a large lateral sweeping between radius and scaphoid. This sliding at the level of the cartilage can head to development of osteoarthritis of the wrist with a horizontal scaphoid and the good cartilage results after proximal row carpectomy. Radio Metacarpal Rotation must be taken into account when a prothesis designing. We propose a wrist locking test. The results of this test are directly related to the capacity of the joint surfaces to transmit pronosupination movements. Radio Metacarpal Rotation shows the importance of the horizontal plane in the wrist and its essential role in the transmission of pronosupination movements.

[Campomelic syndrome. Difficulties in early differential diagnosis from other syndromes involving deformation of the long bones using echography]. / Le syndrome campomélique. Difficultés du diagnostic différentiel précoce par l'échographie avec les autres syndromes de déformation des os longs.

One case of "campomélique" dysplasia discovered by echography at 17 weeks is reported. The details of the syndrome are recalled. In this particular case, only the histology enabled the exact diagnosis to be made. The distinction between "syndrome campomélique" and other syndromes involving deformation of long bones (imperfect osteogenesis of the foetal type and isolated curvature of the tibia) is not easy during early pregnancy using echography alone. At a later stage, the signs and symptoms become more distinct and an exact diagnosis is probably easier.

Hemiplegia--an unusual complication of appendectomy. A case report.

A 12-year-old boy developed complete right hemiplegia and 7th cranial nerve palsy 2 days after laparotomy for a perforated appendix. Full recovery took 2 months. Although it can be accepted that the hemiparesis was not caused by acute appendicitis it is postulated that this unusual association was due either to a septic embolus which lodged in the region of the internal capsule or to a minor cerebrovascular accident.