Parosteal osteosarcoma of the thumb: A case report and literature review.

Parosteal osteosarcoma (PO) is a rare malignant tumor arising from the surface of the bone. Locations in the hand are even more exceptional. This low-grade osteosarcoma shows non-specific clinical and radiological presentation, making diagnosis challenging. Moreover, histologic examination is extremely difficult and can easily lead to misdiagnosis. We report the case of a 21-year-old woman who presented PO of the right thumb, initially diagnosed as a "benign exostosis" 9 years previously. En-bloc resection followed by reconstruction using a free corticocancellous iliac crest autograft provided good esthetic and functional outcome. No recurrence occurred at 2 years' follow-up. Our literature review confirmed the rarity of PO of the hand, with only 8 cases reported in the past 60 years. Amputation was the main treatment, but some authors reported limb-sparing surgery. The present result and those in the literature review support conservative surgery when feasible, with little recurrence and better functional and esthetic results. These rare tumors should not be misdiagnosed, and should be treated in specialized centers to optimize outcome.

Three concomitant locked finger metacarpophalangeal joints caused by degenerative metacarpal heads: Case report.

A locked metacarpophalangeal joint (LMCP) is a rare condition often confused with trigger finger. Its causes are numerous and typically divided into two broad categories: acquired LMCP in younger patients, and degenerative LMCP in older patients. This pathology usually affects only one MCP. Even though several external reduction techniques have been described, the main risk of non-surgical reduction treatment is recurrence. Thus, its management is most often surgical. We report the case of a 60-year-old woman with 3 simultaneous LMCP (3rd, 4th, and 5th rays of the left hand) due to degenerative metacarpal heads. Surgical treatment was performed and found that locking was due to entrapment of the radial collateral ligament on metacarpal head osteophytes. Full extension was regained at the end of the surgery. The follow-up was uneventful, no recurrence occurred. This case highlights the need for careful examination to prevent medical and surgical wandering for a rare but well-described and easy to treat condition.

Entrapment and traumatic neuropathies of the elbow and hand: An imaging approach.

Ultrasound and magnetic resonance imaging currently offer a detailed analysis of the peripheral nerves. Compressive and traumatic nerve injuries are the two main indications for imaging investigation of nerves with several publications describing the indications, technique and diagnostic capabilities of imaging signs. Investigation of entrapment neuropathies has three main goals, which are to confirm neuronal distress, search for the cause of nerve compression and exclude a differential diagnosis on the entire nerve. For traumatic nerve injuries, imaging, predominantly ultrasound, occasionally provides essential information for management including the type of nerve lesion, its exact site and local extension.

[Evaluation of a technical modification to Mannerfelt's total wrist fusion technique in a series of 19 rheumatoid wrists]. / Évaluation d'une modification de la technique d'arthrodèse totale du poignet rhumatoïde selon Mannerfelt. À propos de 19 cas.

We studied a technical modification of Mannerfelt's total wrist fusion technique in a series of 19 wrists. A fully intramedullary technique without dorsal carpal fixation was used to protect the extensor tendons. Two intramedullary Rush pins without dorsal staples were used during the arthrodesis procedure. Nineteen rheumatoid arthritis wrists (2 bilateral cases) were reviewed with a mean follow-up of 4.9 years (range 2-10 years). Clinical outcomes were assessed using the VAS pain scale, DASH-score and wrist strength measurements. Wrist fusion was assessed on AP and lateral X-rays of the wrist. The position of the carpal Rush pin entry points and distal hook orientation were also assessed. Pain was 8.9 preoperatively and 1.1 at the last follow-up with 95% patients satisfied. Mean DASH-score was 46.9 points. The pinch strength was 79% and the grip strength was 68% of the contralateral wrist. Carpal height, carpal anterior subluxation and ulnar deviation were stable at the last follow-up. All of the wrists were in straight position and no extensor tendon ruptures were noted. Fusion was complete in all cases within 6 to 12 weeks, except in one case. The technical modification proposed in the current study -intraosseous fixation only- appears to be a good alternative to Mannerfelt's original technique. Every case treated with this modified technique had good functional results and none required pin removal.

[Middle-term results of a Silastic prosthesis used as a temporary spacer for unreconstructable radial head fractures]. / Résultats à moyen terme d'un implant en Silastic utilisé comme espaceur transitoire dans les fractures non synthésables de la tête radiale.

This study reports the use of silicone prosthesis as a temporary spacer for comminuted fracture of the radial head. Twelve men and eight women with a mean age of 42 years (17-54) were operated on in an average of five days following a comminuted fracture of the radial head. Silicone radial head prosthesis was implanted with a mean duration of eight months (3-18) between implantation and removal. At a mean period of five years after initial surgery, the mean DASH score was 40 (24-82), the mean MEPS score was 86 (60-100) giving ten excellent results, five good and five means. At the last clinical follow-up, the average flexion was 127° (90-140) and 152° (50-180) for pronation-supination. Regarding our results, early removal of the Silastic implant prevented possible synovitis and failure of silicone implant. The stability of the elbow was obtained in all cases with association of a medial collateral ligament repair in case of instability. The use of a silicone radial head implant as a temporary spacer in case of radial head fracture type Mason III or IV seems to be a possible alternative to metal prostheses, whose implantation technique is demanding and sometimes not recommendable in young patients.

The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments.

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

The arthritic wrist. I--the degenerative wrist: surgical treatment approaches.

UNLABELLED: The primary goal in treating a degenerative wrist is to provide pain relief, while maintaining strength and mobility if possible. After failure of the recommended conservative treatment, the choice of approaches can be made from a large collection of techniques, some which are well validated. Partial wrist fusion, particularly the Watson procedure, results in a pain-free wrist in 80% of cases, with 50% of the mobility preserved, good grasping strength and stable results for at least 10 years. Proximal row carpectomy provides similar results if the cartilage on the head of the capitate is preserved and the patient is not involved in heavy manual labour. Complete denervation provides pain relief in almost 80% of cases while preserving motion and strength. This is a safe and effective option, with no age limit, that still allows other procedures to be performed in the future. Total wrist fusion also has its place in revision, and even as first-line treatment, because of the reliable outcome in terms of pain and strength, high satisfaction rates, little to no repercussions linked to the loss of mobility and fewer complications. Other techniques are now available. The partial or complete resection of a carpal bone and placement of an implant is back in vogue because of the availability of pyrocarbon. Such implants are an option in the future for localized osteoarthritis or even diffuse affections, and a useful alternative to more invasive procedures. The use of a rib cartilage graft to partially or completely replace a carpal bone or resurface the radius has promising results in terms of pain reduction and fusion. The role of total joint replacement must be defined relative to the classic, reliable techniques that have long-term outcome data. LEVEL OF PROOF: IV.

Anatomical and radiological assessment of trapezial osteotomy for trapezial dysplasia in early trapeziometacarpal joint arthritis.

Opening wedge osteotomy of the trapezial saddle was reported first by Kapandji and Heim (2002) as a possible surgical treatment for early trapeziometacarpal joint arthritis. This study evaluates the feasibility and anatomical risks of the procedure. Ten upper limbs from fresh cadavers were used for this anatomical and radiological study. A dorsolateral opening wedge osteotomy with a 10 degrees correction was performed on each specimen. CT scans and AP radiographs of all the wrists were performed before and after osteotomy to assess the correction of the slope angle, defined as the angle between the longitudinal axis of the second metacarpal and the axis of the trapeziometacarpal articulation. On standard radiographs, mean trapezial slope was 126 degrees preoperatively and 117 degrees postoperatively. On sagittal and coronal CT reconstructions, one case of trapezial translation and two impingements between trapezoid and trapezium bones were identified. Trapezial osteotomy is technically demanding with several possible complications, but merits further study for young patients with Eaton stage 1 or 2 osteoarthritis and an abnormal trapezial slope.

Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis.

Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.

[Acute closed injuries of the digital proximal interphalangeal joints]. / Les traumatismes fermé récents des IPP des doigts.

Acute closed injuries of the digital proximal interphalangeal (PIP) joints are frequent and can leave sequelae because of imprecise diagnosis of the lesions, poorly adapted treatment, or insufficient follow-up. The therapeutic options proposed in this presentation are advocated by all of the participants and are based on their personal experience and evidence reported in the literature. After a brief anatomic review necessary for the understanding of PIP joint pathophysiology we have presented the longterm outcomes of PIP joint injuries, which are central to the therapeutic decision-making process in terms of risk benefit ratio. To facilitate the presentation, we have separated lesions "with" and "without" fracture. A specific chapter is devoted to surgical approaches essential for successful management of these injuries and another to particular problems related to the seldom reviewed topic of traumatic injury of the PIP joint during bone growth.

[GUEPAR total elbow prosthesis in rheumatoid arthritis. A multicentric retrospective study of 38 cases with an average 4-year follow-up]. / La prothèse totale de coude GUEPAR dans l'arthrite rhumatoïde. Etude multicentrique rétrospective de 38 cas avec un recul moyen de quartre ans.

PURPOSE OF THE STUDY: We conducted a multicentric retrospective analysis of outcome after implantation of 38 GUEPAR elbow prostheses in 36 patients with rheumatoid polyarthritis. MATERIAL AND METHODS: The GUEPAR elbow prosthesis is an anatomic prosthesis developed in 1985 by the Groupe pour l'Utilisation et l'Etude des Prothèses Articulaires (GUEPAR). The recommended surgical technique is described. Patients included in this series had moderate to severe persistent elbow pain. Preoperative motion was 113 degrees flexion with a mean 41 degrees extension deficit. The mean global Mayo Clinic score was 32/100; clinically, the overall assessment was poor in 8 and mediocre in 30. Radiographically there were 16 grade III, 16 grade IV and 4 grade V elbows in the Larsen classification. Two cases were arthroplasty revisions. RESULTS: All patients were seen at a mean 47.6 months follow-up (12 to 97 months). There were two early failures (1 infection and 1 instability) leading to ablation of the prosthesis. Results were analyzed for the 36 remaining arthroplasties. Total pain relief was achieved in 18 cases with only occasional pain in 17 others. Postoperative motion was 132 degrees flexion with a 30 degrees extension deficit, giving a mean 30 degrees gain. The global Mayo Clinic score was 85/100 with 32 excellent, 3 good and 1 mediocre results. Radiography revealed 2 cases of loosening of the humeral component and 1 bipolar loosening that had not required revision at last follow-up. Prosthetic instability was the most frequent among the early and late complications. DISCUSSION: Total elbow arthroplasty is a useful therapeutic option among the treatments proposed (including chemical or isotopic synoviothesis, synovectomy, arthroplastic resection) for rheumatoid elbows. It is indicated for Larsen grades III, IV and V and provides good functional outcome and nearly constant pain relief with an amplitude greater than the 100 degrees, generally accepted as functionally useful. In light of our experience we propose certain modifications of the current GUEPAR implant: adjunction of a condylar extension to the humeral component in order to reduce rotation stress and thus avoid humeral loosening and a radial head element to limit the risk of instability.

[Wear and loosening of prostheses]. / L'usure et le descellement des prothèses.

In 1996, the outcome of any total joint replacement is loosening, occurring usually about 20 years after implantation. Loosening is not a mechanical failure of the bone-implant junction but the consequence of the osteolysis of the periprosthetic bone. It is due to an inflammatory pannus, a tissue constituted by macrophages, which are activated by wear particules originated by the articulating surfaces. The authors showed that this osteolysis is close from that observed with other inflammatory diseases and that it can be obtained with wear particules of many biomaterials, the polyethylene (PE) being the most common in clinical conditions. Several trends in order to reduce polyethylene wear or to replace PE by other materials are presented. Future improvements of the duration of joint prostheses depend on laboratories including surgeons involved in basic research: they are a mandatory link between the engineer and the biologist who study the mechanical and the biological aspects of the wear and of the fixation of biomaterials.

Anatomical relationships and scapular attachments of the supraspinatus muscle.

Ten anatomical preparations and 15 MRI scans (Magnetic Resonance Imaging) performed on healthy subjects were used to define accurately the lateral attachments and anatomical boundaries of the supraspinatus m. Using 5 frozen specimens sectioned in the plane corresponding to the sagittal oblique MRI plane, it was possible to calculate quantitatively the ratio between the bony contours (O) and muscles (M) of the supraspinous fossa. This ratio was maximal (O/M = 2.4) for the section passing through the plane which included the coracoid process anteriorly and the spine of the scapula posteriorly ("Y" section). Five dissections on unembalmed subjects demonstrated that the postero-lateral origin of supraspinatus m. extended further laterally than classically described. This observation was confirmed in the 15 MRI subjects which showed that the supraspinatus m. may arise as far laterally as the "Y" section on MRI in 53% of cases. A quantitative evaluation of atrophy of the supraspinatus m. using MRI is possible with a knowledge of these two parameters.

[Recent isolated lesions of the flexor tendon of the thumb (20 cases). A long-term review]. / Plaies récentes et isolées du Flexor Pollicis Longus (20 cas). Revue à long terme.

PURPOSE OF THE STUDY: This study was performed to assess the long term functional result of Flexor Pollicis Longus tendon repair, with a special interest to the influence of associated neurovascular damages, surgical procedures and rehabilitation techniques. MATERIAL: 20 out 30 patients operated between 1979 and 1994 returned for follow-up (average 5.3 years). The 10 patients lost for follow-up presented no significant epidemiological difference. The location of the laceration was classified according to the international Federation of Hand Surgery Societies (10 T1, 6 T2, 1 T3, 2 T4, 1 T5), and a 3 staged classification of neurovascular bundles damage was used. METHODS: A quantitative evaluation of the active range of motion (extension and flexion) of the interphalangeal joint (IP) was used and allowed calculation of the Tubiana's rating score. The pollici-digital key-pinch was assessed both qualitatively and quantitatively. All the data were compared with the opposite thumb. RESULTS: 85 per cent of patients had excellent or good results according to Tubiana's rating score. The mean flexion of the IP joint was 49.7 degrees (64 per cent of the opposite side), and the key-pinch strength was 69 per cent of its contralateral value. On the opposite, the mean extension was 0.75 degree and 3 patients complained about poor quality of their lateral key-pinch. DISCUSSION: A quantitative evaluation is more meaningful than a global rating score, especially for IP joint lack of extension, and could lead to underestimate the actual patient discomfort. Despite the absence of statistical relevance, lacerations of the 2 neurovascular bundles (stage III) seem to impair the final result. We have found no difference between different types of tendon sutures. A protected post-operative passive rehabilitation seemed to improve both motion and strength of the operated thumb. CONCLUSION: There is no more discussion about the need to repair in emergency all the damaged structures of the thumb. We recommend wrist tendon lengthening when a pull-out suture is used, and when there is an impingement between suture and pulleys in T2 zone. We prefer a controlled-passive rehabilitation.