Elective brachial plexus decompression in neurogenic thoracic outlet syndrome.

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.

Nerve transfers in brachial plexus palsies.

It has been many years now since the introduction of nerve transfers for repair of traumatic brachial plexus lesions and more recently, we have seen its application in the field of obstetric brachial plexus palsy. These nerve transfers do not represent an alternative to anatomical repair by means of nerve grafting, but represent an additional possibility to increase the reconstructive options and improve the final results. This pushes the surgeon to decide: which function is to be restored by nerve grafting, which one by nerve transfer? What is the more reliable procedure? Does the age of the patient, the delay after the accident, or the type of accident influence this choice? If we add in the possibilities of palliative treatment, one can state that many therapeutic options are available today for brachial plexus reconstruction, and that no real consensus does exist. But some tendencies, some trends are apparent.

[Bilateral juvenile trapezometacarpal osteoarthritis in congenital hyperlaxity]. / Rhizarthrose juvénile bilatérale dans une laxité constitutionnelle.

We report a rare case of major trapezometacarpal instability observed in a 31-year-old woman with congenital hyperlaxity. The patient presented major functional impotency of both thumbs, closure of the first commissure, and absence of effective opposition except between the lateral borders of the long fingers due to severe pain in the trapezometacarpal joint attributed to osteoarthritis. The patient underwent bilateral trapezectomy with ligamentoplasty. The gross examination of the trapezeal specimens revealed major cartilage destruction on the medial portion of the trapezeal joint surface. Three months after surgery, the patient was able to resume occupational and recreational activities. At one year, she was pain free with normal function. No other similar case could be identified in the literature and search for a pathological condition which could have contributed to the altered collagen was negative. It was observed that since stabilization was achieved by ligamentoplasty, recurrence should not be expected in congenital hyperlaxity if the tendons are unaffected.

[Comparative anatomy of the hand]. / Anatomie comparée de la main.

The pentadactyl scheme is common to all tetrapods, even in case of adaptative phenomenon (five digits are observed during ontogenesis), or in case of functional convergence The carpal organization with two rows is common too, if we take into account the desappearing of the central bones in mature man. The sellar shape of the trapeziometacarpal joint of the thumb, to often attributed to Man and his only thumb, is in fact the regular shape of all carpometacarpal articulations and present in very ancient primitive primate fossils. Some discontinuous caracters in Man (entepicondylar tunnel) are present in all individuals of some species (carnivors). Rarely present in Man, it can exceptionally produce a real pathology.

[Ralstonia pickettii osteomyelitis of the trapezium]. / Osteite du trapèze a Ralstonia pickettii: a propos d'un cas et revue de la littérature.

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.

The anatomy of the palmar scaphotriquetral ligament.

The palmar ligaments of the wrist were dissected in 15 adult cadaver wrists and demonstrated by MRI in three. Ten fetal wrists (10 to 19 weeks' gestation) were studied in histological sections. The palmar scaphotriquetral ligament was found in them all. Its attachment to the triquetrum is substantial but that to the scaphoid is thin and fan-shaped, its fibres interdigitating with those of the radioscaphocapitate ligament. The contribution of the ligament to carpal stability has yet to be studied, but it may help to support the head of the capitate when the wrist is dorsiflexed.

The posterolateral malleolar flap of the ankle: a distally based sural neurocutaneous flap--report of 14 cases.

The posterolateral malleolar flap is a fasciocutaneous flap designed on the principles of distally based neurocutaneous flaps. It is based distally at the level of the lateral retromalleolar gutter. Elevation of the flap involves the proximal sectioning of the sural nerve, which contributes to its vascularization by reversed flow. This is a very reliable flap, even in patients with distal arterial insufficiency. For this reason, it has emerged, in our experience, as the method of choice in the treatment of heel necrosis. Fourteen cases are reported, of which six were elderly patients.

Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect.

The authors report a simple, single-step procedure to promote the distal transfer of the instep island flap for coverage of the submetatarsal weight-bearing zone. First described in 1991 by Martin et aI, this procedure remained unknown. As opposed to the medial plantar flap, this technique proposes an instep island flap based on the lateral plantar artery. The inflow and outflow of blood is assured by the anastomosis between the dorsalis pedis and lateral plantar vessels. This approach allows for the transfer of similar tissue and provides adequate coverage of the weight-bearing zone of the distal forefoot.

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot.

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.

Partial replantation after traumatic proximal lower limb amputation: a one-stage reconstruction with free osteocutaneous transfer from the amputated limb.

A case of immediate stump reconstruction following proximal leg amputation below the knee is reported. Additional length and sensation are conferred to the stump by free autotransplantation of a composite flap taken from the unsalvageable amputated leg. This flap provided 13 cm of vascularized tibia invested in the skin of the foot. This operative procedure facilitated the fitting of a prosthesis and preserved knee function despite an initial very proximal amputation.

Surgical correction of pseudo-ainhum in Vohwinkel syndrome.

Vohwinkel syndrome or hereditary mutilating keratodermatitis is a rare condition producing palmoplantar hyperkeratosis and constricting rings of the fingers and toes which can progress to compromise neurovascular function and mobility. Medical treatment with oral retinol derivatives is recommended when its use is not contra-indicated. This paper describes surgical correction of the constricting rings on both hands in a 33-year-old woman affected by this condition.

The by-pass extensor tendon transfer. A salvage technique for loss of substance of the extensor apparatus in long fingers.

A salvage technique for the treatment of substance loss of the extensor apparatus with some special features is presented. It uses the extensor indicis muscle prolonged with a tendon graft. The tendon is directly attached to the middle phalanx. After surgery, the wrist is immobilized in extension, allowing immediate active mobilization of the PIP joint. The results in five patients are satisfactory.

Anatomical and biomechanical studies of the pathogenesis of trapeziometacarpal degenerative arthritis.

An anatomical and biomechanical study of the stabilizing ligaments of the thumb trapeziometacarpal joint was conducted on 32 hand specimens. Five main ligamentous structures could be identified. The mechanical properties (in particular, strength) of the five ligaments using a strain-rate failure test were determined and evaluated quantitatively. The maximum tensile strength of each ligament was correlated with the condition of the trapeziometacarpal articular cartilage. In studying the anterior oblique ligament, maximum strength decreased from Grade 0 to Grade 1 by 51%. With the first intermetacarpal ligament, the drop from Grade 1 to Grade 2 was 53%. With the posterior oblique ligament, the decrease was closely related to the grade of the deterioration of the trapeziometacarpal articular surface. These three ligaments also significantly decreased in strength with age. Our results may suggest that the anterior oblique ligament, intermetacarpal ligament and posterior oblique ligament play a large role in stabilizing the trapeziometacarpal joint and that the decrease in their strength is related to the pathogenesis of trapeziometacarpal osteoarthritis.

[High-resolution MRI of the carpal tunnel. Anatomical correlations]. / IRM en haute résolution du canal carpien. Corrélations anatomiques.

This anatomical study of the carpal tunnel compares magnetic resonance imaging sections and adult and fetal anatomical sections. The MRI studies were carried out in 12 normal controls. The use of an experimental high resolution module allows achieving as high a degree of spatial resolution as 0.13 mm2. The comparison of MR images with anatomical sections allows a very accurate analysis of the contents of the carpal tunnel, especially of the median nerve, of the flexor tendons and of the flexor retinaculum.

[The internal plantar island flap. Anatomic study and surgical applications]. / Le lambeau en îlot plantaire interne. Etude anatomique et applications chirurgicales.

Defects of the skin of the heel need to be repaired by skin which is both thick and sensitive. A technique of isolation of an island flap from the non-weight-bearing part of the medial side of the sole is described. It is vascularised by the medial plantar artery and innervated by the medial plantar nerve. Lesions of the heel, the medial malleolus and the lower part of the tendo Achilles can be covered by a one-stage surgical procedure without microsurgical suture.

[Traumatic lesions of the deep branch of the radial nerve]. / Les lésions traumatiques de la branche profonde du nerf radial.

PURPOSE OF THE STUDY: We report a retrospective study of 21 patients treated for an injury of the deep branch of the radial nerve. The aim of this study was to precise the indication and to evaluate the results of nerve surgery and tendon transfer. MATERIAL: 21 patients, mean age 32, with complete divided lesion of the nerve due to open injury were included. 5 cases with fresh discision of the deep branch of the radial nerve were treated in emergency by suture repair. 16 cases were old lesions. 6 of them had initially severe associated lesions involving skin, forearm muscles or radius. In this case, the treatment of the nerve lesion was delayed after the treatment of the associated lesions. 10 were simple lesions of the nerve who were initially misknowned (6 cases) or caused by a surgical procedure at the proximal forearm (4 cases). METHODS: 4 patients had tendon transfers, due to a very old lesion for one of them and a severe muscle involvement for the 3 others. Twelve nerve graft repairs were performed. Their were 8 troncular grafts and 4 fascicular grafts because the lesion was in the posterior forearm at the level of the terminating branches of the nerve. They required a mean length of 5.8 cm and an average of 3 to 4 cables for nerve graft. RESULTS: The mean follow up was 25 months. Results were appreciated on the recovery of 5 functions (supination, fingers extension, thumb abduction, thumb retropulsion, wrist postero-ulnar extension). Primitive nerve repairs had full recovery in all cases. Tendon transfers had good results. The 12 nerve grafts had 2 excellent results, 8 good results, 1 fair and 1 poor result. These 2 last cases required secondary tendon transfers. DISCUSSION: Traumatic lesions of the deep branch of the radial nerve are often misknowned and often iatrogenic. Nerve surgery provides better functional results than tendon transfers. Nerve grafts in delayed nerve repairs are possible even if the lesion is distal. They give excellent or good functional recovery in most cases after a delay of 7 months. Tendon transfers are indicated if nerve surgery fails or in case of large forearm muscle defect, old patient, and when the delay after the injury is superior to 12 months.

[The spinal accessory nerve (n. accessorius) I: anatomical study]. / Le nerf spinal accessoire (n. accessorius) 1ere Partie: Etude anatomique.

INTRODUCTION: In order to increase knowledge of the spinal accessory nerve concerning its situation, trajectory and terminal branches and also the connections with the cervical plexus, the authors report an anatomical study based on 11 dissections of the trapezius muscle mode of innervation and the connections between the accessory nerve, the sternocleidomastoid and trapezius muscles. DISCUSSION: The accessory nerve is a muscular nerve and supplies the main innervation to the trapezius muscle especially for the superior and middle sections. There is a clear participation of the cervical plexus either through the trapezius muscle by nerve anastomosis behind the trapezius or directly especially in the distal portion. CONCLUSION: This anatomical study allows a better understanding of the clinical aspects and the indications of nerve repairs.

[Traumatic lesions of the spinal accessory nerve. II: clinical study and results of a series of 25 cases]. / Les lésions traumatiques du nerf spinal accessoire (n. accessorius) 2e Partie: Etude clinique et résultats d'une série de 25 cas.

INTRODUCTION: Trapezius muscle paralysis after accessory nerve injury was mostly seen after a so called minor surgery of the neck: 17 lesions among 25 appeared after the excision of a cervical cyst or a small benign tumor. This notion should be remembered because the prevention of this paralysis is easy. MATERIAL AND METHODS: In the established lesion, the repair is to be done as soon as possible. The authors report a retrospective study of 25 cases of traumatic accessory nerve injury, followed from 1983 and 1992. A nerve repair was done in 15 cases. It consisted in an average 5 centimeters graft in 10 cases, an intramuscular neurotization in 4 cases, a direct suture in 1 case, and a neurolysis in 6 cases. A palliative treatment was suggested in 4 cases. RESULTS: The mean follow up was 15 months (range 6 to 57 months) and 22 operated cases had more than a 1 year follow up. We observed 10 good results for 10 grafts, 1 good result after 1 direct suture; the 4 neurotisations has 3 good results and 1 average result; the 6 neurolysis had 1 very good, 4 good and 1 poor results and in one case there was no possibility of repair. DISCUSSION AND CONCLUSION: The authors underline the good results after nerve repair following a lesion near from the paralysed muscle and also the need for prevention.

[Covering losses of cutaneous substance of the leg and foot using skin flaps. Apropos of 76 cases]. / La couverture par lambeau des pertes de substance cutanée de la jambe et du pied. A propos de 76 cas.

Between 1983 and 1987, 76 flap grafts were performed in the leg and foot. In general, 3 types of flap were used: --51 ipsilateral flaps, the majority of which were musculo-cutaneous flaps from the medial head of gastrocnemius (17 cases). --17 cross-leg flaps from the opposite limb, the majority of which were medial fascio-cutaneous flaps (13 cases). --8 free flaps, making use of microsurgical techniques. The indications for cross-leg flaps and free flaps have become more limited in favour of local regional pedicle flaps. The lower part of the leg and amputation stumps in the foot are easily covered by distal leg pedicle flaps and amputation stumps of the upper third of the leg can be covered by a flap of fascia lata with a distal pedicle based on the superolateral branches of the peri-articular plexus of the knee.

[Traumatic lesions of the trunk of the femoral nerve and its terminal branches. Apropos of 52 cases]. / Les lésions traumatiques du tronc du nerf sciatique et de ses branches terminales. A propos de 52 cas.

Fifty-two cases of nerves injuries involving the sciatic nerve or one of its two main branches (tibialis or peroneal nerve), between the sciatic notch and the knee, were treated by nerve grafts or nerve sutures. 26 cases were injured in the thigh. They were treated by 11 nerve sutures followed by good results in isolated lesions, and 15 nerve grafts. In 9 cases nerve loss was short and fascicular graft was possible. Clear cut injuries had satisfactory results. In 6 cases, nerve loss was extensive (> 10 cm), especially after sciatic nerve disruption following femoral bone fracture. There was not enough nerve graft available to repair the entire sciatic nerve. Tibialis nerve repair was chosen to restore plantar sensitivity. A vascular nerve graft of peroneal nerve could restore plantar sensitivity in all cases. 26 cases were injured around the knee and involved the peroneal nerve. In 12 cases the lesion was clear cut, treated in 10 cases with a short fascicular nerve graft, and in 2 cases by a suture. In most of the cases, results were good, better than that those obtained after tibialis posterior transfer. 14 cases had peroneal nerve disruption after a severe lateral sprain of the knee. Nerve damages were extensive and results were poor. Tendon transfer had to be done quite often.