Radiological evolution of the rheumatoid wrist after radio-lunate arthrodesis.

Radio-lunate arthrodesis of the rheumatoid wrist is an established technique which has been in use for more than 12 years. The evolution of 26 operated wrists and 20 non-operated wrists has been studied with a mean follow-up of 5 years. The results show that although radio-lunate arthrodesis can prevent dislocation of an unstable wrist, it cannot prevent deterioration. Collapse, ulnar translation, tilt of the lunate, and the inter-carpal instability continued with time, whether the wrists were operated on or not. The speed of deterioration was dependent on the type of rheumatoid arthritis and is faster in the disintegration type than in the osteoarthritis or the ankylosis type. The technique is applicable to the osteoarthritis type of rheumatoid arthritis, in the middle stage (2 to 4a according to the Larsen-Alnot classification). At that stage, the ankylosis type and the disintegration type, and the osteoarthritis type at an advanced stage, are better treated by total arthrodesis or total prosthetic arthroplasty.

Arthrodesis of the trapeziometacarpal joint.

Over a 10-year period, 32 trapeziometacarpal (TM) joint fusions were performed in 29 patients, and reviewed. Pin fixation with tension band wiring was used in 14 cases, screws in eight cases, a plate in six cases, K-wires in three cases and staple fixation in one case. None was bone grafted. Splinting was applied for 4 to 5 weeks. There were four cases of delayed union (more than 2 months) and four cases of non-union requiring re-operation (12.5%). The average follow-up was 6 years and 7 months. Grip (26.5 kg) and pinch (4.9 kg) strength were respectively 7% and 18% less than the normal contralateral side. In bilateral osteoarthritis, grip and pinch were stronger than the contralateral side. Joint angulations measured on X-ray films showed for the peritrapezial joint an 18 degrees arc in flexion-extension (a reduction of 64% compared to the contralateral side) and 11 degrees of arc in abduction-adduction (a reduction of 72%). MP joint mobility increased in extension (160%), in flexion (23%), in abduction (120%), in adduction (157%). Despite the marked decrease in motion, subjective functional complaints were minimal. 78.1% of the patients were fully satisfied, 15.6% partly satisfied, and 6.3% dissatisfied. Pain was absent in 50% of the cases and very mild in 40.7%. Three patients complained of discomfort. Eight patients were noted to have osteoarthritic changes in the scaphotrapezial joint.

[Flexor tendon grafts after provisional implantation of silicone rods. Study and results of 32 cases]. / Les greffes de tendons fléchisseurs après implantation provisoire d'une tige en silicone. Etude et résultats de 32 cas

25 patients (32 fingers) have been operated on following Hunter's technique (flexor tendon grafting after a preparation of the bed by a silicone rod). 24 times the tendon was divided in the no man's land. 2 patients were worsened, 23 improved, 1/3 of the grafted fingers reached the palm in flexion. Results were less satisfactory when several operations had taken place prior grafting, when the graft was long in size. In 3 cases the flexor sublimis tendon was left in place, the graft crossing at the level of the decussassion with good results 6 times, secondary tenolysis led to little improvement. The indications for this operation are detailed.

[Treatment of unstable fractures of the wrist using Hoffmann's external fixator. Study of a series of 40 cases]. / Le traitement des fractures instables du poignet par fixateur externe de Hoffmann. Etude d'une série de 40 cas.

Forty cases of unstable fracture of the distal end of the radius were treated by distraction and fixation using a Hoffmann external fixator. Most of the fractures were both epiphyseal and metaphyseal. They were followed up for between 6 months and 4 years. The anatomical and functional results were generally good; the range of movement of the wrist and its strength were satisfactory. However 4 instances of secondary collapse of the bone could probably have been avoided by a cancellous bone graft. Two severe algodystrophies were observed.

[Unilateral congenital aplasia of the scaphoid and dysplasia of the trapezium (a case report)]. / Aplasie congénitale unilatérale du scaphoïde et dysplasie du trapèze (étude d'un cas).

Aplasia of the carpal scaphoid bone in association with dysplasia of the trapezium is a rare disorder. A right-handed, 66 years old male, suffering from a trapeziometacarpal arthritis on the right side is reported. X rays, MRI and CT-scan reveal an absence of scaphoid and a dysplasia of the trapezium. The lunate remains in place on the radius but is oriented in dorsi flexion. The capitate is dorsally and radially subluxated. Trapezium inclination of the joint at the base of the first metacarpal (trapezial tilt) is 32 degrees greater than on the opposite side which is normal (48 degrees). Radial styloid is hypoplasic. The scaphoid fossa is not covered with cartilage and subchondral sclerotic bone. The intercarpal joints show no trace of arthritis. There are no other deformation on the radial segment of the hand and the forearm. This congenital absence of scaphoid remains asymptomatic and well tolerated excepting the dysplasic trapeziometacarpal joint.

A distally based dorsal and triangular tendinous flap for direct access to the proximal interphalangeal joint.

This dorsal approach allows for a large exposure and provides direct access to the PIP joint. A long triangular tendinous flap with a pedicle based on the insertion of the medial band in dissected from the extensor apparatus and lifted up, leaving the intact lateral bands to slip anteriorally, which exposes perfectly the PIP joint. After joint exposure is achieved and surgery accomplished, this flap is firmly sutured in place and the joint immediately allowed to move. Three cases are presented.

[The history of flexor tendon surgery]. / L'histoire de la chirurgie des tendons fléchisseurs.

Flexor tendon injuries were already treated in antiquity by Hippocrates, Galien and Avicenne. Since the Renaissance, other surgeons have attempted to repair flexor tendon injuries, but without success due to problems related to unsuitable materials and ignorance of the basic rules of asepsis and the absence of antiseptics until the second half of the 19th century. The first successful flexor tendon grafts in man were performed by K. Biesalski in 1910, E. Lexer in 1912 and L. Mayer in 1916. These three authors published their series of grafts and described in detail the anatomical, physiological and technical principles to be respected. St. Bunnell, in 1918, developed various pull-out direct suture procedures, but faced with the problems of adhesions, he abandoned this technique and proposed not to repair flexors in the digital tunnels but to graft them. He defined the famous zone which he called No man's land, which subsequently became Claude Verdan's zone II, in 1959. In 1960, C. Verdan published his first series of sutures maintained by 2 pins in zone II with comparable results to those obtained after grafting. In 1967, H. Kleinert, with his mobile suture, became the leader of direct tendon repair in zone II. 2-stage grafts were introduced in 1965 under the impetus of J. Hunter, who revised and popularized the studies conducted by A. Bassett and R.E. Caroll in 1950.

Paralytic brachial neuritis or Parsonage-Turner syndrome anterior interosseous nerve involvement. Report of three cases.

Paralytic brachial neuritis or Parsonage-Turner syndrome principally involves the shoulder girdle, rarely muscles moving the hand and fingers. Three cases are reported. After an acute episode with severe pain in the arm and fore-arm there appeared, a palsy of flexor pollicis longus and flexor indicis profundus, due to an isolated lesion of the anterior interosseous nerve. Two cases spontaneously recovered their full function, the third incompletely. Delay in recovery may be long; more than two years. Mechanical nerve entrapement should not be confused with this syndrome.

Treatment of algodystrophy using intravenous guanethidine regional block.

25 cases of algodystrophy of the hand have been treated by regional intravenous guanethidine block. Pain relief was noticed in over 2/3 of the algodystrophies in stages 1 and 2, and the patients could carry on their rehabilitation. The treatment is immediately effective easy to use, without side effects and inexpensive. Unfortunately, it is not effective on the third stage of the disease. Hannington-Kiff has reported that the treatment could also be used neuro-algodystrophy of lower limbs. The authors briefly review here the pathogenesis and the clinical findings in neuro-algodystrophy.

Digital contracture deformity after implantation of a silicone prosthesis: light and electron microscopic study.

Following the implantation of a silicone tendon prosthesis for reconstruction of a deep flexor tendon, an extensive, dense, contractile fibrosis developed rapidly. The resulting flexion deformity ultimately necessitated an amputation. The amputated specimen was examined by light and electron microscopy. A great many myofibroblasts were seen in the new tendon sheath, which, because of their contractile properties, probably caused the deformity.

Localized Sudeck's dystrophy and distal interphalangeal osteoarthritis of a finger: anatomicoradiologic study.

After an injury to the right ring finger, a 44-year-old woman experienced pain in the distal interphalangeal joint. A subcutaneous mucoid cyst was noted near the joint. The x-ray films revealed no fracture but a narrowing of the joint space and a well-defined radiolucent area in the ulnar condyle of the middle phalanx. The biopsy specimen of this area excluded infection or tumor and revealed active osteogenic remodelling. These elements permitted a diagnosis of distal interphalangeal osteoarthritis that was associated with highly localized Sudeck's dystrophy (also called " parcellar algodystrophy"). This unusual case suggests the possibility that this dystrophy might be favored by an "osteoarthritic terrain" and might also play a role in the evolution of the osteoarthritis.