Peroneal nerve entrapment.

Sixty patients (sixty-two limbs) who had entrapment of the peroneal nerve were managed with operative decompression, and the results were evaluated after an average duration of follow-up of forty-two months (range, twenty-five to 162 months). The entrapment was postural in five patients, dynamic in two (one of whom had bilateral entrapment), and idiopathic in fifty-three (one of whom had bilateral entrapment). Fifty-eight patients (including the two who had bilateral entrapment) had a positive Tinel sign. Twenty-two patients (including the two who had bilateral entrapment) had sensory symptoms only, and thirty-eight had both sensory and motor symptoms. Electrophysiological studies were performed for all patients in order to confirm the diagnosis. Sensory deficits were confirmed on the basis of a marked decrease in the amplitude of sensory potentials, and motor deficits were confirmed on the basis of decreased nerve-conduction velocities. The common peroneal nerve was decompressed by division of both edges of the fibular fibrous arch. The average time from the onset of symptoms to the operation was fourteen months (range, one to 120 months), primarily because of delayed referrals. Twelve of the twenty-two patients who had had only sensory symptoms preoperatively had complete recovery by the time of the latest follow-up. The average delay from the onset of symptoms to the operation was thirty months (range, six to eighty-six months) for the ten patients (eleven limbs) who did not have full recovery compared with nine months (range, four to thirty-six months) for the twelve patients (thirteen limbs) who did. The postoperative recovery of motor function, as determined with use of the grading system of the Medical Research Council, was good for thirty-three (87 per cent) of the thirty-eight patients who had had both sensory and motor symptoms preoperatively. All seven patients who had peroneal nerve entrapment of known etiology had improvement postoperatively. We recommend operative decompression when symptoms persist or recovery remains incomplete for three to four months, provided that the diagnosis has been confirmed with electrophysiological studies.

Chronic calf pain in athletes due to sural nerve entrapment. A report of 18 cases.

We retrospectively analyzed the charts of 13 athletes (18 limbs) who had sural nerve entrapment localized in the passage of the nerve through the superficial sural aponeurosis. There were 11 men and 2 women (average age, 43 years; range, 31 to 59). All patients reported chronic calf pain that was exacerbated during physical exertion. Delay to diagnosis averaged 9 months (range, 5 to 24). Tenderness in the calf was identified along the course of the sural nerve in all cases. In 10 patients (15 limbs) electrodiagnostic testing before surgery was positive. After failure of nonoperative treatment, surgery was conducted under local anesthesia. Neurolysis was performed by incising the superficial sural aponeurosis and the fibrous band in it through which the nerve passes. The results of the operation were evaluated in terms of residual symptoms, ability to return to the former sport, and degree of patient satisfaction. A final follow-up examination was performed an average of 14 months (range, 6 to 30) after the operation. The final result was excellent in 9 limbs (2 bilateral), good in 8 limbs (2 bilateral), and fair in 1 case. The differential diagnosis of sural nerve entrapment in athletes is discussed. Increase in sural muscle mass or development of local fibrous scar tissue compromised the sural nerve in its course through the unyielding and inextensible superficial sural aponeurosis.

In vitro distribution of ketoprofen enantiomers in articular tissues of osteoarthritic patients.

The distribution of ketoprofen enantiomers in joint tissues was studied as a function of their relative tissular affinities using the multi-chamber distribution dialysis system described by Bickel et al. Selected off-cuts of synovial membrane, joint capsule, cartilage and ligament were obtained from ten patients suffering from osteoarthritis of the knee (n=3) or hip (n=7). Sörensen solution (4 ml) spiked with racemic ketoprofen (2 microg ml(-1)) was dialysed against 1 ml of the four solutions of tissue homogenates (0.4 g ml(-1)). Ketoprofen enantiomers were quantified in buffer and tissue solutions by high-performance liquid chromatography. The distribution of ketoprofen enantiomers in the Bickel's multi-compartment model indicated that there was a non-stereoselective affinity of ketoprofen enantiomers for their potential target tissues. Despite the interindividual variability in articular tissues, the concentrations (+/-S.D.) of R- and S-ketoprofen were significantly higher in synovial membrane (8.69 (4.76) microg g(-1) for S, 9.14 (5.57) microg g(-1) for R), joint capsule (5.71 (2.49) microg g(-1) for S, 5.49 (2.62) microg g(-1) for R) and ligament (6.28 (3.61) microg g(-1) for S, 6.40 (3.64) microg g(-1) for R) than in articular cartilage (3.67 (1.75) microg g(-1) for S, 3.70 (1.67) microg g(-1) for R). There were no significant differences in the distribution of R- and S-ketoprofen between the solutions of joint capsule, synovium and ligament tissues. These data may be related to differences in ketoprofen affinity for the different constituents of joints. This in vitro distribution profile is similar to that reported in vivo for other non-steroidal anti-inflammatory drugs.

Entrapment of the suprascapular nerve.

Operative release for entrapment of the suprascapular nerve was carried out in 35 patients. They were assessed at an average of 30 months (12 to 98) after operation using the functional shoulder score devised by Constant and Murley. The average age at the time of surgery was 40 years (17 to 67). Entrapment was due to injury in ten patients and no cause was found in three; 34 had diffuse posterolateral shoulder pain. The strength of abduction was reduced in all the patients. The average Constant score, unadjusted for age or gender, before operative release was 47% (28 to 53). In 25 of the patients both the supraspinatus and infraspinatus muscles were atrophied and seven had isolated atrophy of the infraspinatus muscle. The average conduction time from Erb's point to the supraspinatus muscle and to the infraspinatus muscle was 5.7 ms (2.8 to 12.8) and 7.4 ms (3.4 to 13.4), respectively. In two patients MRI revealed a ganglion in the infraspinatus fossa and, in another, a complete rupture of the rotator cuff. The average time from the onset of symptoms to operation was ten months (3 to 36). A posterior approach was advocated. The average Constant score, after operative release, unadjusted for age or gender was 77% (35 to 91). The overall result was excellent in ten of the patients, very good in seven, good in 14, fair in two, and poor in two. The symptomatic and functional outcome in our series confirmed the usefulness and safety of operative decompression for entrapment of the suprascapular nerve.

[Nerve compression by mucoid pseudocysts: arguments favoring an articular cause in 23 patients]. / Compression nerveuse par pseudo-kyste mucoïde: à propos de 23 cas. Arguments en faveur de l'origine articulaire.

PURPOSE OF THE STUDY: Mucoid pseudocysts are infrequent benign tumors which can develop on all peripheral nerves near joints. The origin of these cysts remains to be determined. We searched for arguments favoring an articular origin which would have an impact on management and risk of recurrence. MATERIALS AND METHODS: Twenty-three patients (21 men and 2 women, mean age 38 years, age range 13-56 years) presented mucoid pseudocysts and were followed for a mean six years. The mucoid pseudocyst was located on the common fibular nerve at the neck of the fibula in 16 patients, on the tibial nerve at the knee in one, on the median nerve in one, on the ulnar nerve in one, and on the suprascapular nerve in two. Pain was local in 18 patients and irradiated to the concerned nerve territory in 20. Motor deficit was the inaugural feature in 17 patients. EMG was performed in all patients, ultrasound exploration in 15, computed tomography in 7 and magnetic resonance imaging in 10. All patients included in this series underwent surgery: pathological diagnosis of mucoid intra-neural pseudocyst was established in all. Systematic search for communication with the neighboring joint was performed in all cases. RESULTS: An articular communication was found in 17 patients. Mean time to recovery of muscle force (scored 5) and/or normal sensitivity was seven months in 17 patients. One patient did not achieve full recovery. Three patients experienced recurrence and required tibiofibular arthrodesis. DISCUSSION: Three theories have been proposed (cystic degeneration of schwannoma, degeneration of nerve sheath connective tIssue, and an articular origin). The articular theory appears to be the most probable. The presence of an articular pedicle in 60% of the patients, the anatomic juxtaposition between the nerves involved and neighboring joints, and occasional migration along the articular nerve as well as the cyst's mucoid content argue in favor of the articular theory. The notion of recurrence after complete minute excision is also in favor of an articular pathogenic mechanism. The diagnosis of mucoid cyst should be retained as a possibility in patients with rapidly progressive signs of nerve compression near a joint. It is important to search for articular communication before and during the surgical excision in order to limit the risk of recurrence.

[Persistent radial palsy after humeral diaphyseal fracture: cause, treatment, and results. 30 operated cases]. / Paralysies radiales persistantes après fracture de la diaphyse humérale: origine, traitement et résultats. A propos de 30 cas opérés.

PURPOSE OF THE STUDY: Radial palsy is a serious complication of humeral shaft fractures. The risk results from the anatomic position of the radial nerve which turns around the distal portion of the humeral shaft, in contact with the bone. As a rule, radial palsy regresses spontaneously, but in a few cases surgery may be required to achieve neurological recovery. We conducted a retrospective study of thirty cases of radial palsy after humeral fracture treated surgically. Our objective was to define causes of non-recovery and assess therapeutic efficacy, searching for the characteristic features of the fractures involved. MATERIAL AND METHODS: We limited our analysis to post-humeral fracture radial palsies, which were operated due to the absence of neurological recovery. We recorded the type of fracture, treatment used to achieve bone healing, surgical approach, and type of radial nerve surgery. The series included 30 patients, predominantly male, mean age 38.4 years. The fractures were situated in the middle or lower third of the humeral shaft. Most were spiral fractures. Plate fixation (30%) or nailing (33%) were generally used for fixation. There were six cases of iatrogenic palsy, all after plate fixation. A revision procedure was required in one-third of the cases due to nonunion. Exploration of the radial nerve demonstrated compression at the intermuscular septum in one-third of the cases and a direct conflict with the fixation plate in one-fifth of the cases. Neurolysis was required in 23 cases, nerve grafts in five and first-intention tendon transfer in two. RESULTS: Results of nerve surgery were assessed with the Alnot classification at a mean follow-up of 6.3 years. Outcome was rated good or very good in 22 patients, fair in one and poor (failure) in three. First-intention tendon transfers were performed in two patients and two patients were lost to follow-up. Mean delay to recovery was seven months after neurolysis and fifteen months after nerve grafts. DISCUSSION: Our experience and data in the literature suggest that several factors could be involved in persistent radial palsy after humeral shaft fracture. The greatest risk of radial nerve injury or absence of recovery after the primary lesion is encountered after fracture of the lower third of the humerus, spiral fracture, and plate fixation. Particular features observed in our series were nonunion and compression in the intermuscular septum.

[Long head of the triceps brachii in axillary nerve injury: anatomy and clinical aspects]. / La longue portion du triceps brachial dans les traumatismes du nerf axillaire: mise au point anatomique et application clinique.

PURPOSE OF THE STUDY: Earlier work has demonstrated possible paralysis of the long head of the triceps brachii (LTB) after surgical repair of traumatic injury to the axillary nerve. Anatomy textbooks describe the motor branch of the LTB arising from the radial nerve within the body of the triceps. We studied the position of the motor branch for the LTB to determine its exact origin. MATERIAL AND METHODS: Three groups were studied: Group I included 9 traumatic injuries of the axillary nerve associated with clinical involvement of the LTB; Group II included 20 secondary posterior trunks dissected from cadaver specimens; Group III included 15 dissections of the infraclavicular plexus with complete dissection of the secondary posterior trunk. The position of the axillary nerve injury was retrieved from the operative reports for Group I. The precise origin of the motor branch for the LTB was identified for Group II. Neurostimulation was used to identify the origin of the motor branch for the LTB in Group III. RESULTS: For Group I: injury to the axillary nerve was situated 10 mm (mean) from the bifurcation of the secondary posterior trunk in 6 cases and at the bifurcation in 3. Type IV injury was identified in 4 cases and type V in 5. For Group II: the motor branch for the LTB arose 6 mm (mean) from the bifurcation of the secondary posterior branch in 13 cases, at the bifurcation in 5, and 10 mm proximally in 2, but never from the radial nerve. For Group III: the motor branch for the LTB arose 4.5 mm (mean) from the bifurcation of the secondary posterior trunk in 11 cases, at the bifurcation in 4, and never from the radial nerve. DISCUSSION: Observed injuries to the axillary nerve with an associated paralysis of the long head of the triceps brachii were located proximally and were severe. Our dissections always located the motor branch of the LTB arising from the axillary nerve or the secondary posterior branch. We thus deducted that associated LTB paralysis is a sign of poor prognosis. In patients with axillary nerve injury it is a sign favoring a proximal and severe lesion of the axillary nerve. CONCLUSION: When examining patients with traumatic injury involving the axillary nerve, it is important to search for paralysis of the long head of the triceps brachii. If present, it is a sign of a severe axillary nerve lesion requiring early repair at 3 months.

[The treatment of fracture-dislocation of the humeral head by blind pinning (author's transl)]. / Traitement des luxations-fractures de l'épaule sans ouverture du foyer de fracture.

The authors have treated 7 fracture-dislocations of the humeral head by blind pinning. The fractures were reduced by traction under general anaesthesia. 3 or 4 pins were then introduced into the olecranon fossa and driven up through the humeral head. After an average follow up of 29 months, the results were excellent in 9 cases, good in 5 and fair in 3. In 3 cases only, necrosis of the humeral head was noted.

[Common fibular nerve lesions. Etiology and treatment. Apropos of 146 cases with surgical treatment]. / Les lésions du nerf fibulaire commun: approche étiologique et thérapeutique. A propos de 146 cas traités chirurgicalement.

PURPOSE OF THE STUDY: Common peroneal nerve lesion on the lateral aspect of the knee is one of the most frequent neurologic injury of the lower limb. We reported the results of surgical procedure for each etiological group. MATERIAL AND METHODS: In the peroneal nerve entrapment group, we individualised 62 fibular tunnel syndroms (55 idiopathic, 4 postural, 3 dynamic), and 16 external compression. Traumatic causes were represented by 22 varus injuries of the knee and by 11 fractures, 16 iatrogenic lesions, 2 wounds, 5 wound sequelae, 2 contusions and 1 burn. Tumoral group was represented by 7 intraneural ganglionic cyst and 2 extraneural tumour (1 exostosis and 1 chondromatosis of the proximal tibio fibular joint). All patients underwent surgical procedure. Neurolysis was performed when the nerve was in continuity. Suture or nerve grafting was performed in the other cases. In the case of intraneural ganglionic cyst, a complete tumoral excision was realised. RESULTS: Eighty-three per cent of excellent and good results were obtained for the fibular tunnel syndrom, 62.5 per cent for external compression, 36 per cent for varus injury of the knee, 78 per cent for the other traumatic causes and 89 per cent for tumoral lesions. DISCUSSION: This report confirms that the result depends on the etiology of the common peroneal nerve lesion. We propose surgical treatment within 2 to 4 months for the patients without clinical and electrophysiological improvement. If there is doubt on the continuity of the nerve, we propose an earlier surgical treatment. Our results were in general satisfactory except when a nerve graft was necessary furthermore if it was a traction injury and if the length of the graft was longer than 6 centimeters.

[Neurolysis of the median nerve in the carpal canal using a mini-invasive approach. Apropos of a prospective series of 138 cases]. / Neurolyse du nerf médian au canal carpien par une voie mini-invasive. A propos d'une série prospective de 138 cas.

INTRODUCTION: The aim of this study was to assess the results of a prospective study of 138 cases with carpal tunnel syndrome operated on by a percutaneous technique. METHOD: One hundred and twenty-nine patients (108 women and 21 men, with a mean age of 49.9 years) underwent preoperative assessment via a questionnaire and a clinical examination (the Weber test, buckle test, Kapandji test, Tinel test, Phalen test, Vainio test and grip force assessment). The surgical technique was singularised by the insertion of a probe cannula in the carpal tunnel so that the blade could be guided during annular ligament section. RESULTS: The results were assessed at one, three and six months follow-up: 98.5% very good and good results were obtained (Kelly criteria); two patients presented with an algodystrophic syndrome. No vascular, tendinous or neurological complications were noted, and the procedure was in no instance switched to an open technique. DISCUSSION: The main advantages of this technique are a rapid recuperation of hand function, with an average of 22.6 days off work, a low complication rate, and simple equipment.

[Surgical management of traumatic lesions of the axillary nerve: 83 cases]. / La prise en charge des lésions traumatiques du nerf axillaire: à propos de 83 cas opérés.

Axillary nerve injuries still go undiagnosed far too often despite their frequency. However the quality of the outcome depends on expert management and prompt surgery. To optimise the latter, we re-examined 83 operated cases of traumatic lesions of the axillary nerve. We analysed the neurological and functional recovery of these patients by means of a follow-up evaluation at 6 years postop. The results were classified by age, mechanism of injury, delay to surgery and the presence or otherwise of associated neurological or osteo-articular lesions. We highlighted that a high index of suspicion ought to exist in all cases of trauma to the shoulder in a patient aged more than 40, any injury associated with palsy of the long head of triceps and in the case of an osteo-articular lesion due to high-velocity trauma. A complete lack of shoulder abduction must always prompt a search for a lesion of the axillary nerve as well as a suprascapular nerve palsy or rotator cuff lesion. There are few literature reports of surgical management of this particular nerve injury. An early MRI scan as part of the management should improve results by a reduction in the delay before surgery. As a result of our investigation we conclude that a lesion of the axillary nerve without signs of recovery at 3 months should be referred to a centre specialized in peripheral nerve surgery.

[Traumatic hepaticoportal fistula. Apropos of a case]. / Fistules hépatico-portales traumatiques. A propos d'un cas.

A case of post-traumatic hepaticoportal arteriovenous fistula between common hepatic artery and portal vein is reported. This localization of the lesion is exceptional, and early, marked clinical manifestations allow rapid diagnosis and treatment before the development of a portal hypertension.

PreFix™ external fixator used to treat a floating shoulder injury caused by gunshot wound.

Open fractures of the shoulder are extremely rare, and their treatment is a major challenge for surgeons. Only cases encountered in military settings have been reported thus far. Such fractures are often the result of ballistic trauma, which causes extensive damage to both bony and soft tissues. Since these injuries are associated with a high risk of infection and the presence of comminuted fractures, external fixation is necessary for repair. Use of external fixators and revascularization techniques has reduced the number of cases requiring shoulder amputation or disarticulation. Injury to the proximal extremity of the humerus, acromion, and clavicle further complicates the treatment. No published studies have described the assembly of external fixators for fractures in the scapular region with significant bone loss. In addition, no cases have been described in civilian settings. However, with an increase in urban violence and the traffic of illegal arms, civilian surgeons are now encountering an increasing number of patients with these injuries. In this report, we not only present a rare case of floating shoulder injury in a civilian setting but also provide an overview of the existing treatment strategies for this type of trauma, with special focus on the use of external fixators in elective shoulder arthrodesis and on military cases.

Acetabular fracture: long-term follow-up and factors associated with secondary implantation of total hip arthroplasty.

HYPOTHESIS: The present study sought to determine long-term outcome in acetabular fracture and the factors associated with secondary implantation of a total hip arthroplasty and/or with poor functional results. MATERIAL AND METHODS: Seventy-two patients admitted between 2000 and 2005 were followed up for a maximum 11 years (mean, 6.8 years): 16 females, 56 males; mean age at injury, 41.6 years (median, 40 years). There were 45 simple acetabular fractures, 27 complex fractures and 27 dislocations. Late complications were: osteoarthritis (n=29), osteonecrosis of the femoral head (ONFH: n=8) and heterotopic ossification (n=2). RESULTS AND DISCUSSION: Twenty-five total hip arthroplasties (THA) were performed, with a mean time to surgery of 3.7 years. Associated factors for THA were: VAS (P<0.0001), PMA (P<0.0001), osteoarthritis (P<0.0001), ONFH (P<0.0002), initial dislocation (P=0.0002), no functional treatment (P=0.0014), surgical treatment (P=0.0065), initial traction (P=0.0068), anterior and posterior congruency defect (P=0.0072 and P<0.0001), and initial intra-articular foreign body (P=0.045). Factors associated with poor or bad functional results were the same, plus: etiology (P=0.0021), BMI (P=0.03) and posterior wall fracture (P=0.0325). LEVEL OF EVIDENCE: 4; retrospective study.

Total hip replacement pseudotumoral osteolysis.

We report three cases of pseudotumoral lesion secondary to total hip replacement using metal on polyethylene bearings, presenting two distinct macroscopic aspects: (a) classic inflammatory granuloma and, in one case, (b) onset of hematoma associated with gluteal vessel lesions, probably affected by the pseudotumoral process. Diagnosis was radiographic, with CT-scan serving to confirm and, more importantly, to reveal extension and analyze surrounding tissue. Arteriography is needed when the lesion is liquid, and biopsy may be envisaged depending upon the clinical situation. In all three cases, histology was typically that of granulomatous lesions related to wear debris. Once diagnosis could be established, treatment was similar in both presentations, with surgical revision, which should be as early as possible in case of cortical bone involvement, to prevent pathologic fracture.