Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series.

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

General principles of tendon transfers: The ten commandments.

Transferring a muscle's point of force application by modifying its distal insertion will modify its function. This is the basic principle of tendon transfers. Despite being less popular due to superior primary nerve repair results, hand surgeons must be familiar with them. When used according to the Ten Commandments we propose, they provide good and useful functional recovery. Obviously, it depends on the number of muscles available for transfer. Tendon transfer is useful not only in nerve trunk palsy and brachial plexus lesions but also in upper limb tetraplegia rehabilitation. Tendon transfers are active palliative treatments under voluntary command and can be combined with other palliative procedures (arthrodesis, tenodesis) to improve the functional result. Nevertheless, they are far from ideal, as they re-allocate the remaining forces of the limb but do not create new ones.

[Results of Blauth Palmar Flap in congenital syndactyly: Long-term outcome in a 31 webs study]. / Évaluation du lambeau palmaire de Blauth lors de la prise en charge des syndactylies congénitales : à propos de 31 commissures.

OBJECTIVES: The main purpose of our study was to assess the web creep rate of congenital syndactyly treated with a Blauth palmar commissural flap. METHODS: Every child with at least one syndactyly, simple or complex, syndromic or not, were included in this study. The main criterion of this study was the web creep rate according to the Withey scale (0 to 4). Scar assessment according to the Vancouver Scar Scale, hair growth and/or dyschromia on the full-thickness graft, digital spacing, flexion deformity, clinodactyly, range of motion of the finger, sensitivity and satisfaction were also assessed. RESULTS: Separation of the webbed fingers was performed in 65 syndactylies between 1993 and 2015. The median age at the time of surgery was 14 months. We reviewed 31 web flaps with a mean follow-up time of 9 years. Fifty eight percent of the webs were grade 0 on the Withey scale, 36% were grade 1, 6% were grade 2. There was no grade 3 or 4. No correlation was found between the age at the time of surgery, gender, web space involved, complexity of the syndactyly, and the web creep. A decrease in range of motion and a flexion deformity of the fingers involved were more frequently found in complex syndactylies. Eighty seven percent of full-thickness grafts presented dyschromia, and 42% abnormal pilosity. CONCLUSION: Palmar flap as described by Blauth is a safe technique ensuring good functionals outcomes and a low web creep rate for the reconstruction of the web space in congenital syndactyly.

Long-term outcomes of proximal row carpectomy: A series of 62 cases.

The aim of this study was to determine and analyze the functional and radiographic outcomes after proximal row carpectomy (PRC). We hypothesized that this surgery could restore wrist mobility and function in case of radiocarpal osteoarthritis or severe carpal trauma. Sixty-two patients who had undergone PRC were included in this study: 44 patients with wrist osteoarthritis (11 SNAC, 24 SLAC, 3 Kienböck's disease, 6 other) and 18 patients with severe carpal trauma. Each patient underwent clinical (pain, range of motion, grip strength, functional scores) and radiographic evaluations. At the latest evaluation after a mean of 11.8 years, 15 patients (24.2%) required revision total wrist arthrodesis surgery in a median of 22 months (range, 6-179) because of disabling pain and lack of strength. The failure was statistically correlated with being young and a manual laborer. The range of motion and strength of the operated wrist were 61.5% and 70%, respectively, compared to the contralateral side. PRC remains a reliable procedure for treating wrist arthritis and severe carpal trauma. However, manual activity and being under 50years of age can lead to an early salvage procedure such as total arthrodesis of the wrist. In this subset of the population, another alternative must be considered.

Silicone infusion tubing instead of Hunter rods for two-stage zone 2 flexor tendon reconstruction in a resource-limited surgical environment.

The authors describe their experience using silicone infusion tubing in place of Hunter rods for two-stage zone 2 flexor tendon reconstruction in a resource-limited surgical environment. This case report features a 47-year-old, right-handed man who had no active PIP and DIP joint flexion in four fingers of the right hand 5 months after an injury. During the first repair stage, the A2 and A4 pulleys were reconstructed using an extensor retinaculum graft. An infusion tube was inserted instead of Hunter rods. During the second stage, formation of a digital neo-canal around the infusion tubing was observed. The infusion tubing was removed and replaced with a palmaris longus tendon graft according to the conventional technique. Physiotherapy and rehabilitation followed surgery. At 6 months, very significant progress had been made with complete recovery of PIP and DIP flexion in the four fingers.

Upper limb nerve transfers: A review.

While upper limb nerve transfers were first described and performed several years ago, they have seen expanded use in the past 20 years. Initially indicated for surgical repair of brachial plexus injuries with nerve root avulsion, the indications have been extended to post-ganglionic lesions because of the excellent results of certain intraplexus nerve transfers. The traditional nerve repair techniques - primary suture and nerve grafting - form the basis of nerve surgery. Although nerve transfer does not replace them, they are a useful supplement as they provide a targeted approach to reinnervation and recovery of key functions of the upper limb. The goal of this review is to provide an overview of the various possible transfers by the function being restored and the quality of the outcomes.

Recovery of rock climbing performance after surgical reconstruction of finger pulleys.

UNLABELLED: This study evaluated recovery of sport performance and correction of bowstringing after surgical reconstruction of closed finger pulley rupture in high-level rock climbers. A total of 38 patients treated with an extensor retinaculum graft were assessed. The mean follow-up time was 85 months, and 30 patients returned to their previous climbing level. The mean total active motion score was 96% of the opposite side. All patients had an excellent Buck-Gramcko score. There was no significant difference in grip strength and tip pinch strength in the crimp position between the injured side and the opposite side. A total of 31 patients were examined with ultrasonography. In 18, flexor bowstringing effects had returned to near-normal values. There was an association between rock climbing level recovery and the flexor bowstringing correction (odds ratio, 6.9; 95% confidence interval, 1.1-42.8). If flexor bowstringing was corrected, patients were more likely to regain their preinjury sport performance. The ultrasonography measurement was a useful tool for predicting functional recovery. LEVEL OF EVIDENCE: 4.

[Not Available]. / Traitement des séquelles de brûlures de la main dans les pays à ressources limitées ; notre expérience en république démocratique du Congo.

Burn injuries to the hand are still common in low-income countries. Between December 1st 2010 and May 1st 2014, 32 patients, representing 38 hands, were admitted and treated at the University Clinics of Kinshasa in the Democratic Republic of Congo (DRC). We observed 22 patients (69%) in the juvenile age group (under 18 years old) and 10 patients (31%) in the adult age group (18-59 years). We did not observe any patients in the senior age group (60 years and over). In the juvenile age group, those aged from 1 to 5 years old were the most affected, comprising 13 patients (40%). Accidents occurred mainly at home (72%). The most common burn etiologies were thermal injuries caused by flame (51%) and scalds (34%). Contractures were the most frequently occurring lesions (84%). Overall dorsal retraction, known as "claw hand", was found in 40% of patients, and was associated with keloid and hypertrophic scars in 84% of cases. Excision and grafting were performed in 43.7%, local flaps in 43.7% and distant flaps in 12.5% of cases. On discharge from hospital, 84% "good" results were observed. Follow-up lasted 18 months. This study demonstrates the feasibility of reconstructive surgery in sequelae of hand burns, despite limited resources. However, the challenges in low income countries with limited resources are numerous: poor access to current techniques of plastic surgery, inadequate initial burns management, and poverty.

Results with the Roseland(®) HAC trapeziometacarpal prosthesis after more than 10 years.

The Roseland(®) hydroxyapatite-coated prosthesis is a total trapeziometacarpal joint prosthesis used for the surgical treatment of thumb basal joint arthritis. The aim of this retrospective study was to evaluate its long-term outcomes. Fifty-one patients (64 thumbs) underwent trapeziometacarpal joint replacement with this prosthesis. The mean follow-up was 12.5 years. Survival rate of the prosthesis was 91%. There was either no pain or only occasional pain in 91% of cases. The mean QuickDASH score was 27.6. Abnormal radiographic findings were present in 70% of cases. Since they were often asymptomatic, no further treatment was carried out. Complications were common (25%) and occurred early on but could often be treated without surgery. The long-term results with the Roseland(®) HAC prosthesis are satisfactory in terms of pain relief and function. However, the high complication rate is a major concern.

[Lower limb salvage with a free fillet fibula flap harvested from the contralateral amputated leg]. / Un cas de "jambe-banque" pour le sauvetage d'un membre inférieur.

We report a unusual case of "fillet flap" to reconstruct the lower limb with the amputated contralateral leg. This kind of procedure was first described by Foucher et al. in 1980 for traumatic hand surgery as the "bank finger". A 34-year-old man suffered a microlight accident with bilateral open legs fractures. A large skin defect of the left leg exposed the ankle, the calcaneus and a non-vascularized part of the tibial nerve (10 cm). The patient came to the OR for surgical debridement and had massive bone resection of the left calcaneus. The right leg showed limited skin defect at the lower part, exposing the medial side of the ankle and a tibial bone defect, measuring 10 cm. Salvage the left leg was impossible due to complex nerve, bones and skin associated injuries, so this leg was sacrificed and used as a donor limb, to harvest a free fibula flap for contralateral tibial reconstruction. At 18 months of follow-up, the patient was very satisfied, the clinical result was very good on both lower limbs and X-rays showed excellent integration of the free fibula flap. The patient had normal dailies occupations, can run and have bicycle sport practice with a functional left leg fit prosthesis. This case showed an original application of the "fillet flap concept" to resolve complex and rare traumatic situations interesting the both lower limbs. In our opinion, this strategy must be a part of the plastic surgeon skills in uncommon situations.

[Stab wounds of the hand and forearm due to Kuluna in Kinshasa (Democratic Republic of Congo): types of injuries and treatment]. / Plaies de la main et de l'avant-bras par arme blanche dues au phénomene Kuluna à Kinshasa (République Démocratique du Congo): types de lésions et traitement.

Democratic Republic of Congo (DRC), a particular form of juvenile delinquency and insecurity intensifies in the city of Kinshasa. This is the phenomenon Kuluna. It is organized gangs equipped with machetes and other weapons. The main objective of this study is to know the phenomenon Kuluna and describe the upper limb injuries caused by machetes, while insisting on the specifics of the management of these lesions in our communities. This retrospective descriptive study examines 14 cases of wounds of the hand and forearm due to stab phenomenon Kuluna, in Kinshasa. It covers the period from 1 November 2010 to 1 November 2013. Among the 14 patients with lesions in the hand and forearm admitted and treated at the Unit of Plastic Reconstructive and Aesthetic Surgery, Hand Surgery and Burns, University Clinics of Kinshasa to attacks due to the phenomenon Kuluna. We have 11 men and 3 women. The average age was 33, 5 years (extremes of 21 and 56 years). The right upper limb is reached that the left upper limb, respectively 12 patients and 2 patients. The lesions are localized to the wrist in the majority of cases (10 patients) in the palm of hand and in 3 patients in the fingers in 1 patient. The palmar surface is reached (10 cases) and the dorsal (4 cases). Zone 5 of the International Classification of flexor and Zone 8 topographic classification extensors at hand are the predilection sites of lesions respectively the palmar surface (6 out of 10) and the dorsal (2 case 4). The median nerve at the wrist is cut in half the cases. On bone lesions localized to the forearm, we observed a high incidence of fracture of the ulna (62.5%). The treatment begins with the stabilization of bone pieces, gestures revascularization and nerve sutures and suture tendon and finally skin coverage. Rehabilitation was mandatory, she supervises the actions of repair and it continues until the recovery of function.

[Management of zone 1 flexor digitorum profundus tendon injuries]. / Prise en charge des lésions du tendon fléchisseur profond des doigts en zone 1.

Flexor tendons repair in zone 1 is classically considered providing good results with an overall satisfactory finger function. However, the objective functional results after surgical repair of flexor digitorum profundus are sometimes disappointing. The authors describe the different surgical repair techniques available to the operator from so-called "traditional" sutures to newer methods of internal fixation using miniaturized anchor sutures. The management of postoperative procedures, that of failures and old cases are reported.

[Flexor tendon repair: a short story]. / Une histoire de la réparation des tendons fléchisseurs.

This short story of flexor tendon repair aims to illustrate hesitations and wanderings of this surgery. Obviously tendon repair was very early considered, but it developed and diffused rather lately. It became a routine practice only in 20th century. This was due on the one hand, in Occident, to the Galen's dogmatic interdiction, on the other hand, to the repair difficulties of this paradoxical structure. Actually tendon is made of fibroblasts and collagen (sticky substances), and then its only goal is to move. According to this necessity, whatever the used techniques are, gliding is the final purpose. Technical evolutions are illustrated by historical contributions to flexor tendon surgery of several "giants" of hand surgery.

[Functional magnetic resonance imaging. What are the benefits expected in hand surgery?]. / IRM fonctionnelle. Quels apports en chirurgie de la main ?

Functional MRI (fMRI) allowed considerable advances upon understanding of cerebral functioning. Cortical plasticity, which allows the voluntary command of a restored function by a transferred muscle remains to be investigated in its intimacy. The authors present here the round table held at the 48th annual meeting of the French Society for Surgery of the Hand on December 22nd, 2012. It tries to review the analysis of the phenomenon observed during multiple tendinous transfers for restoration of proximal radial nerve palsy. Were successively approached: 1) Methods of acquisition and analysis of the signals (C. D-M.); 2) Movement reorganization (O.M.); 3) Motor plasticity after hand allograft (A. S.); 4) The potential interest of the fMRI in hand rehabilitation (F. D.); 5) The analysis of cerebral plasticity in general (H. B.). A rather philosophical conclusion opens other fields to f MRI (A.M.).

[Foreign body reaction in osteoarthritis of the trapeziometacarpal joint treated by trapezectomy and interposition of a L-polylactic acid "anchovy" (Arex®615R). A series of eight cases]. / Réaction à corps étranger dans les rhizarthroses traitées par trapézectomie et interposition d'un « anchois ¼ en acide L-polylactique (Arex®615R). À propos de huit cas.

Osteoarthritis of the trapeziometacarpal joint is a common pathology. When the trapezium is not large enough to allow using a total joint arthroplasty or in case of peritrapezial osteoarthrosis, the authors used a trapeziectomy with interposition of an absorbable L-polylactic acid anchovy (Arex(®)615R). This technique is simple and fast. From 2006 to 2010, out of 68 implants, nine displayed a prolonged inflammatory reaction, both clinically and radiologically abnormal, leading the patients to undergo revision surgery for removal of the implant before the end of the third postoperative year. Histological analysis highlighted in all the cases a resorptive gigantocellular immune foreign body reaction.

[Necrotizing fasciitis: study of 17 cases presenting a low mortality rate]. / Dermo-hypodermite bactérienne nécrosante avec fasciite nécrosante : à propos de 17 cas présentant un faible taux de mortalité

UNLABELLED: Necrotizing fasciitis is a hypodermis, muscular fascia then dermis necrotizing infection. OBJECTIVE: The originality of this study is to present a series of necrotizing fasciitis treated and followed these last five years, and to compare the therapeutic results with those of the literature. PATIENTS AND METHODS: We led a retrospective study on the patients treated for necrotizing fasciitis between 2005 and 2009 by bringing together the demographic and clinical data, the bacteriological examinations and the results of management. Follow-up data from these patients during period of study (five years) were notified. RESULTS: Seventeen patients were treated (11 men and six women). The average age of the patients was 52 years (ranging from 28 to 82 years). Risk factors of necrotizing fasciitis for our patients were: nonsteroidal anti-inflammatory drugs (82.2%), cutaneous wound (76.4%), obesity (29.4%), oto-rhino-laryngologic diseases (23.5%), alcoholic and drug addicts (23.5%), and diabetis (11.7%). The most isolated and responsible germ was Streptococcus pyogenes in 75.5% of cases. Culture of specimens collected before antibiotic treatment showed that the bacterium was sensible to the antibiotics being administered (clindamycin in 70.5% of cases). The surgical management was early done with an average delay of 2.7 days (ranging from 1 to 15 days). We observed a low mortality rate (11.7%). One patient died during the period of follow-up after one year (average follow-up of 2.0 years; 1-3 years). CONCLUSION: Contrary to the data from the literature, this study presents a decrease of the mortality in necrotizing fasciitis with an early treatment and an adequate management. The precocity and the quality of surgical procedures as well as the presence of an underlying disease are determining factors for successful management of necrotizing fasciitis.

[Repair of nose, lips and chin mutilations. The customary repairs versus allografts]. / Réparation des mutilations du triangle nasolabio-mentonnier. Plasties conventionnelles versus allogreffes.

Central-facial mutilations, located within the nose lips and chin triangle, require great quality repairs regarding morphology and function. Plastic surgery history affords the ideas evolution in this field crossing over nose and lips reconstructions, which were the subject of successive reports within our society, in 1994 (nose reconstruction) and 2002 (lips reconstruction). Now a day, following this progress, the plastic surgeon has a large choice of reliable techniques. His choice is dictated by a precise evaluation of the limits of the substance loss to repair, according to a (mapping) classification of the nose-lip and chin triangle. This classification defines three units (nose-labial, bilabial and chin-labial) as reflexion bases to the therapeutic indications. This anatomical and surgical approach was built starting from a retrospective study of 195 central-facial mutilations caused by ballistic damage and dog bites. The results evaluation makes possible to carry out a reflexion on the potential indications regarding allograft as a therapeutic alternative to the traditional reconstructions of this territory.

[Treatment indications for hand agenesis or acquired loss: Standard technics versus allotransplantation (CTA)]. / Une main vous manque et... Indications thérapeutiques des agénésies et amputations de mains : plasties et prothèses versus allogreffes.

The new surgery thinking, in matter of hand loss, is made of two ways: without hand, there is no more functional abilities; homograft or allograft of hand is the best actual treatment. This is not true and we are able to get new functional abilities by other ways: without any treatment, we are able of spontaneous functional recovery. There are other treatments: the old operation of Krukenberg or new bionic prosthesis. This work is a recall of obvious or forgotten facts.

[Roseland® prosthesis: quality of life's studies about 68 patients with a mean followed-up of 43.8 months]. / Prothèse Roseland®: étude de qualité de vie de 68 patients avec un recul moyen de 43,8 mois.

OBJECTIVES: Roseland® prosthesis is a ball and socket prosthesis, physiological and not anatomical. This study wants to demonstrate by a quality life questionnaire (quick DASH described by Dubert et al., 2001) that Roseland® prosthesis gives to patients a trapeziometacarpal joint native capacities. PATIENTS AND METHODS: An exterior examinator reviewed prospectively 68 patients having a mean age of 61.1 years at surgery with 11 bilateral cases that is 79 prothesis. With a mean follow-up of 43.8 months, we value by Kapandji's opposition, first comisssural openning, quality of life and patient's satisfaction. RESULTS: Three patients have been excuded: two of them had got post-traumatic dislocation: one trapezium fracture, one unknown reason. The third patient had got osteophytis with "came" effects. We keep 65 patients with 84,6% satisfying and very satisfaying. 75,4% of patients have a capacity of 80% and more of their joint, 40% of them had got 100%. DISCUSSION: Roseland® prosthesis has good results because it agrees with already known principles as on its own concept: rotula prothesis gives three axes mobility, as on its own conception: metarcarpal stem with a palmar "T" shaped against rotation and bone saving, a cup with equatorial ring to prevent burying of the spongy bone. Componenents are recovered by hydroxyapatite to favour osteo-integration with less loosening than ciment. An accurate technique avoids dislocations traps: trapezium implant centring, internal osteophytis removal. An accurate indication: trapeziometarpal joint osteoarthritis only (second degree's Dell classification). CONCLUSION: Roseland® prosthesis reproduces a satisfactory and functional joint for 84,6% of cases. These good results can be obtained by accurate indication (Dell II) and contra-indication (osteoarthritis around trapezium except trapeziometacarpal of course).

Pins and rubber traction system for intra-articular proximal interphalangeal joint fractures revisited.

The Pins and Rubber Traction System (PRTS) can be used to treat proximal interphalangeal intra-articular fractures. Our experience is that outcomes are not always excellent and that many patients have reduced joint function or residual deformities. The aim of this study was to evaluate the reasons behind the poorer outcomes of some of the patients treated with this system. A retrospective clinical and radiological evaluation was performed on 15 patients after a minimum of 2 years' follow-up. The mean interphalangeal joint flexion range was 66 degrees (range 0-100) in our series. The review of the literature shows an average active interphalangeal joint flexion of 78 degrees (range 64-95). Reasons for this difference include preoperative delay, technical deficiencies, the learning curve, a lack in postoperative physiotherapy and degenerative changes due to the longer follow-up. Although the Pins and Rubber Traction System seems a simple procedure, a learning curve is necessary to avoid pitfalls.