Removal of cancellous bone graft through the base of the excised radial styloid process.

In performing STT arthrodesis, the excision of the tip of the radial styloid avoids further radial styloid impingement. Cancellous bone graft can be obtained through the base of the excised radial styloid, using a trephine or a curette. The amount of bone removed is sufficient for intercarpal arthrodesis.

Wartenberg's sign. A new method of surgical correction.

A method of surgical correction is described for Wartenberg's sign, or persistent abduction of the little finger, using a slip of the extensor digitorum communis of the ring finger. The transferred component can be either the central slip, or the ulnar slip extended by the connexus intertendineus to the little finger. This technique maintains the integrity of the extensor mechanism of the little finger, avoiding loss of active extension, which is frequently observed when extensor digiti minimi is used. The donor site is dependable since the extensor digitorum communis tendon of the ring finger is always composed of several slips. This technique should be considered only in cases of isolated persistent abduction of the little finger, when there is no claw deformity.

Scapho-trapezio-trapezoid arthrodesis in the treatment of Kienböck's disease. A study of 16 cases.

Sixteen scapho-trapezio-trapezoid arthrodeses were performed for Kienböck's disease. In ten cases, a prosthetic replacement of the lunate was inserted at the same time. Clinical results were good with regard to pain and fair with regard to grip strength which was improved by an average of 32%. In contrast, the arc of flexion-extension was 38% less than on the unoperated side. Long-term radiographic assessment showed the efficacy of the procedure in maintaining carpal height. Biomechanical observations and a review of poor results showed the limits of the method and the importance of correct positioning of the scaphoid. We concluded that triscaphe arthrodesis was a useful procedure for the treatment of Kienböck's disease in Decoulx's stage 3.

The posterior interosseous flap in primary repair of hand injuries. A review of 23 cases.

The posterior interosseous flap has been used for resurfacing in 23 cases of hand injury in the past 5 years. There was complete necrosis in two cases, partial necrosis in three and temporary post-operative nerve palsy in one.

[Absorbable osteosynthesis: experimental and clinical approach in surgery of the hand]. / L'ostéosynthèse résorbable: approche expérimentale et clinique en chirurgie de la main.

Given the advances in the field of high molecular-weight polylactides, it is now possible to obtain biomaterials of great strength with a resorption rate that ranges from a few months to several years. Experimental evaluation of the biomaterials was done in rabbits with implantation of intramedullary rods after fracture of the knee. The results of histological studies and assessment, using MR imaging, indicated good compatibility of the intramedullary rods. Applications for human clinical practice centered on metacarpophalangeal arthrodesis of the thumb performed for rheumatoid polyarthritis and intractable sprains of the metacarpophalangeal. Operations were performed on 52 patients with a rate of consolidation of 96%. No synovitis-like reactions were observed concurrent with massive release of the biomaterial. As a first step, this type of osteosynthesis could be applied to the upper extremity where stresses are relatively minimal. Eventually, screws of reduced diameter could be developed for the treatment of articular and unstable fractures of the metacarpophalangeals. There are already 3.5 mm-screws that can be used for malleolar fixation at the level of the lower extremity. Because of the wide variety of biomaterials that are currently available, it is important to be familiar with their composition, so that patients will be spared certain complications linked to resorption, especially inflammatory reactions. The biomaterials presented here belong to a class of biomaterials that have demonstrated good compatibility. At the present time, the cost of biodegradable materials remains high but it is important to emphasize the social and economic consequences of their use, since there is no need for a secondary procedure to remove them.

[Arthrolysis of the wrist, indications and technique]. / Arthrolyse du poignet, indications et technique.

The authors describe a technique of arthrolysis which can be used on the palmar aspect of the wrist, on the dorsal aspect, or on both capsular and ligamentous complexes. The procedure must not be performed before inflammation and retraction phenomena of capsular and ligamentous complex have completely ceased. The surgical procedure must be followed rigorously but is not especially difficult. Criteria for patient selection are emphasized because proper indication is crucial to ensure satisfactory results.

[Arthrodesis of 4 bones of the wrist. Study of 12 follow-up cases]. / L'arthrodèse des 4 os du poignet. Analyse de 12 cas revus.

From November 1988 to December 1990, 15 four-bone fusions (capitalum-lunatum-triquetrum-hamatum) were performed in our department. 3 cases were lost at follow-up, so we here describe 12 cases reviewed for a clinical and radiologic evaluation. Etiologies were as follows: advanced scapholunate dissociation: 5 cases; advanced pseudarthrosis of the scaphoid: 6 cases; ulnar midcarpal instability: 1 case. Follow-up averaged 18.8 months with a range of 6 to 29 months. Pain was significantly lessened: 9 patients had either no pain, pain influenced only by weather, or pain after sustained effort. Results for strength were average. Joint motion was severely restricted, with individual variations among patients. Remaining joint motion was of little use, and some activities of daily living were thus hampered. Pre and postoperative radiologic analysis of the carpus showed that repositioning the proximal row into the distal row of bones was not necessary. In order to obtain a good result, it suffices to stabilize the existing carpal collapse without attempting to restore carpal height. Study of this short series showed the efficacy of this arthrodesis as regards to pain although it significantly decreased the range of motion.

[Non-articular malunions of the distal radius: evaluation and techniques of correction]. / Les cals vicieux extra-articulaires du radius distal: evaluation et techniques de correction.

Malunion remains the most common complication following fracture of the distal radius. Deformities can be observed in all three planes with displacement in dorsal or palmar tilt, translation, shortening and axial rotation. Preoperative evaluation requires a comparative analysis with clinical, radiological and scanographic assessment. The functional consequences affect the radiocarpal and distal radio-ulnar joints and the carpus. Biomechanical aspects include changes in pressure forces on the distal radius and ulna, and displacement of the centers of rotation. If present, associated lesions should be evaluated. The degree of clinical acceptance depends on each patient, but generally functional outcome is closely correlated with the anatomic result. Limits of radiological acceptance should be defined at 20 degrees dorsal tilt, 5 degrees radial inclination, and a - 4 mm distal radio-ulnar index. Corrective osteotomy is performed on the radius, with or without a complementary ulnar procedure. Closing wedge and re-orientation osteotomies are no longer used. Opening wedge osteotomy with or without lengthening is preferred, generally with an access on the same side as the sagittal tilt. The osteotomy should be performed just above the distal radio-ulnar joint. A temporary external fixator provides the best way to check peroperative corrections. Bone grafts may be harvested from the radius or the iliac crest. Pins and cast are sufficient to immobilize the dorsal tilt corrections. In case of volar tilt, an internal plate fixation is best. Depending on the status of the distal radio-ulnar joint, a conservative (shortening osteotomy, wafer procedure) or non-conservative (Darrach-Moore, Kapandji-Sauvé.) procedure should be performed on the ulna. If needed, associated lesions of the carpus must be treated. Surgical correction is mainly indicated in case of a functionally unacceptable deformation, but should be discussed if the radiographical limits have been overrun. The goal of such corrective procedures is to recover anatomical restitution.

[Pseudarthrosis and delayed union of the distal phalanx of the long fingers. Apropos of 13 cases]. / Pseudarthroses et retards de consolidation de la phalange distale des doigts longs. A propos de 13 cas.

PURPOSE OF THE STUDY: The authors present 13 cases of delayed or non-union of the distal phalanx of the long fingers treated surgically. MATERIAL AND METHODS: The patients were all men aged from 41 years to 60 years. The involved digits were 4 second, 2 long, 5 ring, and 2 little fingers. The operated side was the right side 5 times, the left one 8 times, the dominant one 4 times. Ten cases were due to inadequate treatment of the initial fracture. The three others cases had no clear explanation. Three types of incisions were used: transverse distal, lateral or an extended one combining the two previous. Bone stabilisation was made either, by longitudinal K wires or with a small cancellous screw. In 7 cases, bone grafting was needed. RESULTS: Bone healing was obtained in 9 cases in an average time of 9 weeks. Further procedures included: 2 distal amputations after septic conditions, 2 removals of distal bone fragment and 2 fusions of the distal interphalangeal joint. Overall results evaluated by the patients themselves were fair, including 2 excellent, 6 good (but 2 after distal interphalangeal joint arthrodesis), 2 mild (1 after distal interphalangeal joint arthrodesis), 1 poor and 2 failures. DISCUSSION: The type of skin incision was chosen according to the bone condition; distal in cases of fibrous nonunion when fibrous tissue removal and bone grafting were needed. Neither the type of bone stabilisation (pinning or screwing) nor the donor site of bone grafting influenced the final result. CONCLUSION: The authors would like to stress the importance of an adequate treatment of finger injuries in a emergency situation, considering the difficulties to restore secondarily a satisfactory functional outcome.

[Correction of posttraumatic disorders of the distal radio-ulnar joint with the Sauvé-Kapandji surgical procedure]. / Correction des désordres post-traumatiques de l'articulation radio-ulnaire distale par intervention de Sauvé-Kapandji.

The Sauve-Kapandji procedure was performed on 21 patients with posttraumatic lesions between May of 1985 and May of 1991; average clinical and radiological follow-up was 3.4 years. Causal mechanisms were as follows: 12 cases were sequelae of fractures of the distal extremity of the radius; 5 cases were sequelae of fractures of the diaphyses of the two forearm bones and/or of the head of the radius; 2 cases of instability of the distal radio-ulnar joint; 2 cases of posttraumatic isolated arthritis of the distal radio-ulnar joint. Subjective evaluation by the patients of the results of surgery was as follows: 8 excellent, 6 good, 2 satisfactory and 5 poor. The most consistent improvement was a gain of mobility in pronation and supination which averaged 87 per cent of that of the healthy contralateral side. Nine patients were free of pain, 6 experienced some pain only during effort, and 6 still suffered constant pain. Grip strength was the factor that changed the most: it averaged 55 per cent of that of the healthy contralateral side. Indications for the Sauve-Kapandji procedure and its results in posttraumatic lesions are discussed. This procedure is compared to other techniques used to correct posttraumatic disorders of the distal radio-ulnar joint.

[Scapho-trapezo-trapezoidal arthrodesis or triscaphe arthrodeses. Study of 36 reviewed cases]. / L'arthrodèse scapho-trapézo-trapézoïdale ou arthrodèse triscaphoïde. Etude de 36 cas revus.

From May 1983 to September 1988, we performed 41 triscaphe arthrodeses, 36 of which underwent clinical and radiologic follow-up examination. The 36 preoperative diagnoses were classified as: Kienböck's disease (16 cases), chronic rotatory subluxation of the scaphoid (static scaphoid-lunate dissociation) (13 cases), degenerative arthritis of the scapho-trapezio-trapezoid joint (4 cases), traumatic lesion of the scapho-trapezio-trapezoid joint (2 cases), 1 case of midcarpal instability with a non-dissociative VISI pattern. Average length of follow-up was 28 months. Analysis of results showed on the whole good improvement on pain and average improvement of strength; range of motion varied greatly with etiology. For example, the range of motion on the fused side in Kienböck's disease averaged 38 per cent of that of the unoperated side, whereas in other conditions it averaged 60 per cent. Radiographic analysis confirmed the efficacy of triscaphe arthrodesis in preserving normal carpal height but revealed radial styloid impingement in 34 per cent of the cases. Use of this procedure should be limited to stage 3 Kienböck's disease and to scaphoid-lunate dissociation without arthritis. Peroperative radiographic study is indispensable to verify appropriate reduction of the scaphoid and to measure the radial-scaphoid angle. Partial radial styloidectomy should be included routinely in the procedure.

[Osteosynthesis using a L-shaped miniplate of metaphyseal and metaphyseal-epiphyseal fractures of metacarpals and phalanges]. / Ostéosynthèse par mini-plaque en "L" des fractures métaphysaires et métaphyso-épiphysaires des métacarpiens et des phalanges.

In 15 cases, a small L-shaped, cut-to-size, reversible plate was used either to stabilize metaphyseal and metaphyseal-epiphyseal fractures of metacarpal bones and first phalanxes or to correct malunions and non-unions. The material and operating technique are described and the advantages and disadvantages of this and other techniques are discussed.

[Patient-rated wrist questionnaire: preliminary report on a proposed French version of a North American questionnaire designed to assess wrist pain and function]. / Auto-évaluation de la douleur et de la fonction du poignet. Proposition d'une version française d'un questionnaire nord-américain et essai préliminaire.

We present a French translation of a North American self-assessment questionnaire (Patient Rated Wrist Questionnaire or PRWE). This questionnaire was developed by Joy MacDermid and members of the IWI (International Wrist Investigators). Three years were needed to establish the specific items and questions to get a valid and reliable questionnaire. It includes 5 questions on pain and 10 questions on function. All the questions were rated on a 0-10 scale. The questionnaire provides several scoring options with a total of 100. MacDermid assessed the responsiveness of three questionnaires (DASH, SF-36 and PRWE) in 59 patients after distal radius fractures. Standardised response means (SRM) were calculated to indicate responsiveness. The PRWE was the most responsive. The French version was evaluated on 20 patients. All the questions were understood. The mean writing time was 5 minutes (3 min - 7 min).

[Temporary external fixation in the correction of non articular mal-unions of the distal radius]. / Le fixateur externe temporaire dans la correction extra-articulaire des cals vicieux du radius distal.

PURPOSE OF THE STUDY: The authors reviewed 21 cases of extra articular malunions of the distal radius treated by osteotomy, temporary external fixation, then osteosynthesis. Two groups were studied: Group A of 14 patients with dorsal tilt of the distal radius and Group B of 7 patients with palmar tilt of the distal radius. Mean follow-up of this series was 69 months ranged from 12 to 109 months. MATERIAL AND METHODS: In Group A, after exposure of the distal radius through a dorsal approach, the site of osteotomy, proximal to the distal radio-ulnar joint, was determined by fluoroscopy. The angular correction was done by progressive opening using a small external fixator. After checking on the correction, the bone graft was harvested 7 times on the radius as described by Watson et Castle, 7 times on the iliac crest. Bone fixation was done by two K-wires and a cast for 8 to 10 weeks. Three Sauvé-Kapandji procedures was done at the same time. In Group B, the approach was palmar, extended distally to open the carpal tunnel. The distraction was done with a distal T-shaped external fixator. The bone graft was always harvested on the iliac crest. Bone fixation was done with a T-shaped palmar plate. Two Sauvé-Kapandji procedures was done at the same time. RESULTS: Group A: Flexion-extension arc was improved of 15.5 p. 100, pronation-supination of 83.7 p. 100 and grip strength of 80 per cent of the pre-operative values. Radiological evaluation showed good correction except one case of undercorrection of the dorsal tilt (-7 degrees) and one case of undercorrection of the radial inclination (+6 degrees). The distal radio-ulnar index was measured at the mean of 0mm postoperatively compared to +5 mm pre-operatively. One patient developed a postoperative radiocarpal arthritis. Group B: Flexion-extension arc was improved of 96.2 p. 100, pronation-supination of 76.9 p. 100 and grip strength of 108.3 p. 100 of the preoperative values. Radiological evaluation showed good correction except one case of overcorrection of the palmar tilt (-10 degrees) and one case of undercorrection of the radial inclination (+7 degrees). The distal radio-ulnar index was measured at the mean of 0mm postoperatively compared to +7 mm pre-operatively. DISCUSSION: The functional consequences of malunions of the distal radius have been stressed by others for more than sixty years. Since, many authors have contributed to refine and improve their surgical correction. Several displacements should be taked into account for the preoperative planning. They are sagittal tilt, frontal horizontalisation, shortening, sagittal and frontal translation, and axial rotation. Many types of osteotomies could be done; closing wedge, opening wedge or reorientation. In some cases, an operative procedure of the distal radio-ulnar joint should be done at the same time. We chose an opening-wedge osteotomy and the use of a temporary external fixator to ensure progressive distraction and good adjustment in the correction of angular deformities. In the dorsal tilt group we were satisfied in using on 7 patients a trapezoidal cortico-cancellous bone graft harvested on the radius. CONCLUSION: The authors would like to stress two points: The technical interest of using a temporary external fixator to adjust the angular correction of the distal radius. The importance of an adequate treatment of distal radius fractures in emergency situation, considering the functional and cosmetic alterations due to malunions and their need for surgical corrections in main instances.

[Island bone graft from the second metacarpal to the first metacarpal]. / Greffe vascularisée en îlot du deuxième métacarpien pour allongement du premier métacarpien.

We report a case of reconstruction of the first metacarpal by using an extended vascularized bone graft taken from the distal part of the second metacarpal. Following a gunshot injury, a 57 year-old man presented with a thumb amputated at the interphalangeal joint level and an index finger amputated at the metacarpophalangeal joint level. After lengthening of the first metacarpal over a six weeks period, the bone gap was filled using a vascularized 2.4 cm-length piece of the second metacarpal. This graft was vascularized by the dorsal vascular network of the first web space. At two months, the bone fixation was removed. At five months, the bony integration was complete.

[The DASH questionnaire. French translation of a trans-cultural adaptation]. / Le questionnaire DASH. Adaptation française d'un outil d'évaluation international.

The DASH (Disability of Arm-Shoulder-Hand) is a self-administered questionnaire developed in 1994 by representatives of the Institute for Work & Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS). It measures the physical disability and symptoms for all upper limb disorders in a heterogeneous population and for acute as well as chronic disorders. The original american version has been already tested for reliability and validity. Interest in the DASH was raised by several European publications. It appeared that the DASH could provide a common measure for upper extremity physical disability in Northern America and European countries. For this cross-cultural adaptation, we followed the guidelines developed by the Institute for Work & Health and American Academy of Orthopaedic Surgeons. Five translations and two "back-translations" were compared, aiming to semantic, idiomatic, experimental and conceptual equivalence. The final version has been tested in 223 patients presenting a variety of traumatic or non traumatic disorders. 208 questionnaires (93%) were valid because there was less than 4 missing answers. This final version has been proposed to American Academy of Orthopaedic Surgeons in order to be endorsed as an official translation. This could improve assessment for international studies by establishing standard measures.

[Injuries of the flexor tendons of the hand]. / Les plaies des tendons fléchisseurs à la main.

Diagnosis of clear-cut severing of the two flexor tendons is simple and obvious. This is not true for isolated injury to a single tendon and for partial severing. In this case, careful clinical examination and routine surgical exploration of any wound with regard to the course of the flexor tendon is required. Surgery should aim at the least traumatic repair possible, followed by specialised rehabilitation directed by the surgeon. In the distal region, reinsertion into the bone is required. In other regions, suture consists of a the main suture with a continuous suture of the epitendineum. The region of the digital canal requires rigourous care due to its specific anatomy. The corollary to good surgical repair is rehabilitation, understood and complied with by the patient. Early mobilisation procedures are used predominantly in order to avoid the formation of postsurgical adherences.

[Coverage of dorsal distal skin defects of the digits. Techniques and indications]. / Couverture des pertes de substance cutanée distales des doigts. Techniques et indications.

Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area is challenging according to the following points: the proximity of the distal interphalangeal joint, the thinness of the extensor apparatus and the vicinity of the nail. Among the numerous flaps described, the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.

[Interest of using muscle flaps in the coverage of small ankle and distal leg defects]. / Intérêt de l'utilisation des muscles locaux dans la couverture des petites pertes de substance de la cheville et du quart distal de jambe.

The author reports his experience and the interest in using small pedicled muscle flaps in the coverage of small cutaneous size defects around the ankle and the distal leg. In such defects, the bad cutaneous status often precludes the use of fasciocutaneous flaps, and the use of wider muscle pedicled flaps or even free flaps is excessive. Because of their small sizes, the muscles used in our series, often considered as accessories, appear very useful.

[Hemosiderotic fibrohistiocytic lipomatous lesion: a new entity you must remind]. / Tumeurs fibrolipomateuses hémosidérotiques: une nouvelle entité à ne pas méconnaître.

Fatty tissues lesions are the most frequent of both benign (lipoma) and malignant tumor (liposarcoma) of soft tissues in the adult. We here describe the case of female patient having a fatty tissue mass of the ankle corresponding to an hemosiderotic fibrohistiocytic lipomatous lesion (HFHLL). This very rare tumour of recent description is specific of the ankle/foot area of the middle age women. These lesions are always benign and frequently recur following incomplete resection. This tumor may have invasive local growth and metastases have not been described so far. We describe the anatomopathologist's key points of their diagnostic. We discuss the main differentials diagnosis and treatment.