[Pronator quadratus repair using the Henry approach with an outward-return running suture]. / Réparation du pronator quadratus par surjet aller-retour dans la voie de Henry.

Repair of the quadratus pronator after osteosynthesis of the distal radius via the Henry approach is generally considered a difficult procedure. The quadratus pronator is a powerful muscle which stabilizes the distal radioulnar joint. The muscle is most often injured in association with distal fracture of the radius. Apposition osteosynthesis appears to be the most appropriate procedure in order to limit loss of reduction, i.e. distal radioular variance, observed in the first postoperative weeks. Tendon complications observed with dorsal approaches and the development of new volar plates with locking screws have offered new prospects for the Henry approach. We propose here a technique for repairing the pronator quadratus with an outward-return running suture using a 2.0 single-strand thread. The technique is designed to redistribute tension along the muscle borders progressively and precisely. Muscle integrity can thus be restored and the flexor system is isolated from the osteosynthesis material.

Treatment of unstable proximal interphalangeal joint fractures with hemi-hamate osteochondral autografts.

The primary aim of this study was to assess the clinical and radiological results after hemi-hamate resurfacing arthroplasty in patients with acute or chronic unstable fractures of the base of the middle phalanx and to describe technical features that can facilitate the surgical procedure. Hemi-hamate arthroplasties were done in 19 patients (mean age 39 years) with an isolated fracture at the base of the middle phalanx that involved more than 40% of the articular surface. We assessed ten chronic cases (treated >6 weeks after fracture) and nine acute ones (<6 weeks) at a mean of 24 months. Pain scores, QuickDASH scores, grip strengths, range of motion and radiological findings were recorded at follow-up. At follow-up, the mean active flexion at the proximal interphalangeal joint was to 83° with a mean fixed flexion of 17° (active range of motion 66°). The mean active distal interphalangeal motion was 41°. The mean visual analogue scale score was 1.1. The mean QuickDASH score was 11. The mean pinch strength was 82% of the opposite side. Radiographs revealed one partial graft lysis. LEVEL OF EVIDENCE: IV.

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.

Slipped capital femoral epiphysis: evaluation of different modes of treatment.

We reviewed 91 hips with slipped capital femoral epiphysis (SCFE) after an average follow-up period of 6 years 6 months. Different treatment methods used, according to types and stages of slipping, are discussed. In situ fixation appears to be the best procedure for SCFE with < 60% displacement. Careful reduction-fixation is indicated in acute and acute-on-chronic SCFE > 60%. Primary rotation osteotomies are associated with a high percentage of complications. Secondary osteotomies should be simple (preferably a subtrochanteric derotation osteotomy) to reduce the risk of necrosis. Preventive contralateral fixation is indicated when the growth cartilage is still open.

[Cholecystectomy: the cost of surgery]. / Cholécystectomie: le coût de l'acte opératoire.

290 patients who underwent cholecystectomy with operative cholangiography were included in the study. Operating time and material cost of each operation were prospectively measured for each patient. The mean operating time was 107 min, and the median time was 100 min. Differences in operating time between surgeons were statistically significant. The shortest mean operating time was 68 min, and the longest was 136 min. The mean cost of material used was 158 francs. The lowest mean cost was 113 francs, and the highest was 174 francs. Such measures of operating time and costs for usual and standardized operations are possible. They should be used to establish a more objective fee system for operations inside a surgical specialty, and between different specialties.

[C5-C6 and C5-C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions]. / Les paralysies traumatiques C5-C6 et C5-C6-C7 du plexus brachial de l'adulte par lésions supraclaviculaires.

PURPOSE OF THE STUDY: In C5-C6 and C5-C6-C7 brachial plexus palsies, prognoses was based on the recovery of a useful shoulder and elbow in order to control a normal or partially impaired hand. Treatment was an integrated procedure combining direct nerve surgery and muscle transfers. MATERIAL: Our study was performed on 27 cases of C5-C6 plexus palsy and 43 cases of C5-C6-C7 plexus palsy operated between 1984 and 1994, with an average delay between trauma and surgery of 8 months. METHODS: Elbow flexion was obtained by nerve surgery on the anterior part of the primary trunk or directly on the musculo-cutaneous nerve and after muscle transfer. Nerve surgery on supra-scapular nerve, on posterior part of primary trunk or directly on axillary nerve was also performed. RESULTS: The results were analyzed separately for shoulder and elbow flexion and globally. In C5-C6 palsies, elbow flexion was a goal which has been reached in 100 per cent of cases. Only 56 per cent of cases obtained a stable shoulder with active external rotation. In C5-C6-C7 palsies, elbow flexion was reached in 86 per cent of cases and stable shoulder with active external rotation only in 26 per cent. Reinnervation of the elbow flexors was reached by direct nerve surgery in 60 per cent of C5-C6 and 52 per cent of C5-C6-C7. Active external rotation was reached by spinal-suprascapularis nerve neurotization in 60 per cent of C5-C6 and 54 per cent of C5-C6-C7. DISCUSSION: No significant difference after nerve surgery for elbow flexion was found between C5-C6 and C5-C6-C7 plexus palsies. Failures of nerve surgery will undergo muscle transfer. When C7 is damaged, less muscles are transferable and results are less good. For shoulder, best results were obtained after spinal suprascapularis nerve neurotization with direct suture. In case of failure, a derotation osteotomy was performed. If shoulder was still unstable, transposition of the coracoacromial ligament to the humerus was also performed. CONCLUSION: In C5-C6 palsies, elbow flexion is a goal which must be reached in 100 per cent of cases. Prognosis depends of shoulder function. In C5-C6-C7 palsies, results are less good. 6 patients did not recover elbow flexion, no active mobility of the shoulder was observed in 63 per cent of them. The results obtained for elbow flexion are satisfactory if the program does not separate nerve surgery and muscle transfers.

Tendon transfers to restore elbow flexion after traumatic paralysis of the brachial plexus in adults.

Loss of elbow flexion after traumatic brachial palsy produces significant functional and cosmetic problems. Although a direct approach to the neurological lesion with an attempt to reinnervate the biceps has given some encouraging results, these can be incomplete and for this reason tendon transfers still have an important role. We report the results of our series of 60 patients (54 men and 6 women) who have undergone tendon transfer between 1984 and 1994. The transfers were performed during or after nerve surgery, and we used the muscles arising from the medial epicondyle, the pectoralis minor and the triceps. Our results were judged on any improvement in shoulder stability and in the power of lateral rotation, together with the power and range of active and passive flexion of the elbow. Good results were achieved in 74% of the patients in our study, with more than 120 degrees of elbow flexion and an ability to support at least 1 kg with the elbow flexed to 90 degrees.