Modeling and concepts of the Malingue plasty compared to Z-plasty.

Malingue's diamond-shaped skin plasty is a random skin plasty derived from the Z-plasty. Not widely known, this technique is an alternative to fasciectomy in Dupuytren's disease. The main objective of the present study was to analyze the topographical and anatomical differences between Z-plasty and Malingue plasty in cadaveric and experimental models and the geometrical and mathematical differences in modeling, in order to determine the respective gains in length. The study was carried out in two steps. An anatomical step on a cadaveric model studied vascularization. The second step was based on inert models (latex gloves) and cadaveric models, to study the mechanical behavior of the flaps. Differences in gains in length were analyzed by Euclidean and non-Euclidean geometry. The Malingue plasty flaps showed greater vascular richness than in Z-plasty. The experimental cadaver and inert material models showed 50% length gain with a single Malingue plasty, versus 33.3% with Z-plasty. The gain decreased in multiple plasties: respectively, 25% and 17.5% with double plasty and 20% and 16.7% with triple plasty. The analysis of Euclidean plane geometry did not explain these results, whereas 3D analysis on non-Euclidean geometry can explain a superior elongation effect in the Malingue plasty. The Malingue plasty could be an interesting option when significant lengthening is required, especially when Z-plasty would be insufficient.

Benefits of a collagen membrane for recurrent ulnar nerve entrapment at the elbow: A series of 40 cases.

The rate of failure or recurrence after ulnar nerve release at the elbow is up to 25%. Various biomaterials have been developed to protect nerves from postoperative adhesions. The aim of this study was to review a case series of 40 surgical revision procedures of the ulnar nerve at the elbow, protected by a collagen membrane (Cova™ ORTHO). Forty patients who had this revision surgery between January 2013 and December 2017 were reviewed: 34 were evaluated in person, 6 were evaluated over the phone. The operation consisted in release of the ulnar nerve, anterior subcutaneous transposition and nerve protection using a collagen membrane. We assessed the following parameters with an average follow-up of 4 years and 3 months: paresthesia, night awakening, quality of life (QuickDASH score) and neuropathic pain (DN4 questionnaire). The outcome was determined with the Gabel & Amadio score. The patients' satisfaction was evaluated. A significant decrease in paresthesia and night awakening was found (p < 0.05). The average Gabel & Amadio score improved from 4.4 to 6.7 with 5 excellent, 19 good, 9 fair, and 1 poor result. The average DN4 was 5/10 and the QuickDASH score was 40.1. Eighty percent of patients were satisfied or very satisfied with the outcome. Surgical revision of the ulnar nerve at the elbow remains a delicate operation without a gold standard. This case series found good or excellent results in 70% of patients. Surgical revision of the ulnar nerve with a collagen membrane is a reliable alternative among other possibilities for ulnar nerve release at the elbow.

Revision of Arpe® trapeziometacarpal prosthesis by isolated head and linear exchange in five patients.

With the increase in the number of trapeziometacarpal arthroplasties being done, the indications for revision due to implant wear will also increase significantly in the coming years. Isolated linear exchange in the context of polyethylene wear without osteolysis or loosening of the implants is already well known in the case of hip arthroplasty. This revision option offers the advantages of less morbidity, faster recovery, and bone preservation. We retrospectively reviewed five patients who underwent trapeziometacarpal revision with isolated polyethylene liner exchange. Revision surgery was performed an average of 17.6 years (10.7-21.3 years) after the primary arthroplasty procedure. The indication for revision was dislocation in four cases and prophylactic revision for wear and limited osteolysis of the cavity in the other case. Mean follow-up was 48.7 months (36-60). One patient had a recurrent dislocation 4 years after revision and required another revision where only the cup was changed. The other patients had no instability, and no complications were reported. The mean QuickDASH score was 11.9 (4.5-15.9). Pinch strength was 102% (90-120) and grip strength was 92% (70-110) relative to the opposite side. Radiological evaluation showed no abnormalities at the last follow-up. Trapeziectomy is often the solution of choice in the surgical revision of arthroplasties. Unipolar revision of the cup has the risk of trapezium fracture, especially when the cup is well integrated. The technique we report here preserves bone and simplifies the surgical procedure with outcomes corresponding to those of primary arthroplasty. Isolated exchange of the polyethylene liner is a relevant option in the revision of trapeziometacarpal arthroplasty with good short-term results.

Vein conduits used to enhance arterial microsurgical end-to-end suture repair: A randomized comparative study.

Wrapping microsurgical sutures with a vein conduit is a well-described procedure for microsurgical nerve repair. While this has rarely been described in the context of vascular repair, this technique could increase the permeability of the sutured vessels. As part of a University Diploma in Microsurgery, 9 junior surgeons performed a comparative study of 18 microsurgical repairs on rats with and without vein sleeve. The vessels used were an external jugular vein sleeve on the end-to-end anastomosis of the common carotid artery and comparing it to this same anastomosis without a sleeve. The data analyzed were rat weight, suture time with carotid clamping time, number of stitches used, complications as well as vascular leakage and permeability of the repair at 0 and 5minutes evaluated with a patency test. The average rat body weight was 255g. Mean suture time was 52minutes in group A (sleeved repairs) and 41minutes in group B (standard repairs). The number of stitches placed was 5.1 points on average in group A and 5.6 points in group B. The time to perform the repair and the number of stitches was not statistically different between groups. The patency test was positive in 100% of cases in group A and in 78% of cases in group B. There was a significant difference between the permeability rate of the repairs, with better results in group A (p=0.03). There were two anastomotic leaks after declamping in the sleeve group and five in the standard suture group, thus 2.5 times more leaks in the group without a sleeve (p<0.01). The addition of a vein sleeve around an end-to-end arterial suture repair seems to improve its permeability and therefore its reliability.

Middle phalangectomy with shortening fusion of the fifth finger in Dupuytren's digital hooks.

Severe contracture of the little finger due to Dupuytren's disease continues to be a therapeutic problem. Fifth finger amputation, which is sometimes the only solution, has a major negative impact on function and appearance, and exposes the patient to adjacent digital hook aggravation. Middle phalangectomy with finger shortening fusion is an alternative surgical solution. The aim of this study was to report on a continuous series of 36 cases treated with this approach. This was a retrospective series of 33 patients (26 males and 7 females) operated from 1994 to 2015. All patients had severe contracture of their little finger and 30 had prior surgery. The combined extension lag was 143° (75-270), with considerable functional deficit and poor appearance. The surgical technique consisted of a dorsal approach, a more or less extensive excision of the middle phalanx, and arthrodesis with alignment of the remaining bone segments, while preserving the fingertip/nail complex. The following outcomes were determined when the patients were reviewed: functional discomfort and use, appearance, residual pain, pulp sensitivity, recurrence of contracture and overall satisfaction. Six patients were dead and two were lost to follow-up. Twenty-five patients (27 cases) were reviewed at a mean follow-up of 64 months (12-280). There were no post-operative complications. Twenty-two patients (24 cases) were satisfied or very satisfied. The resulting appearance was graded at 7.13/10 (1-10). Pain on a 10-point Visual Analog Scale was 0.46 (0-5). Cold intolerance was found in 9 cases (33.3%) and decreased fingertip sensitivity in 3 cases (11.1%). The hand could be flattened in 21 cases; in the other cases, it could not be flattened due to contracture in another finger. Wearing gloves was again possible in 26 cases. Fusion was achieved in 18 of the 21 cases evaluated with X-rays at the last follow-up (85.7%). All the other cases had a non-union with no clinical repercussions. There were 5 local recurrences at the level of the little finger. Finger shortening through a dorsal approach seems to provide satisfactory outcomes in patients with Dupuytren's disease who have severe contracture of the little finger. This technique results in an acceptable looking functional finger, which has sensation and no significant morbidity.

Vein conduit with microsurgical suture repair of superficial branch of the radial nerve injuries at the wrist.

The superficial branch of the radial nerve (SBRN) at the wrist is susceptible to trauma and lacerations. These lesions can develop into painful neuromas with debilitating consequences. The aim of our study was to demonstrate the effectiveness of systematic use of vein conduits associated with microsurgical suture repair in SBRN injuries to prevent the occurrence of these neuromas. Our study was retrospective and performed at a single site. An independent examiner performed the clinical assessment. The study included 33 patients and the mean follow-up was 63 months. We looked for a so-called "trigger point". None of the patients developed a painful neuroma or experienced any pain. All the patients were either satisfied or very satisfied with their treatment. Systematic use of vein conduit in SBRN injuries at the wrist helps prevent the occurrence of painful neuroma and the disorder's inherent consequences, which can be severe not only clinically, but also socially and professionally.

[Results of a 5 years follow-up of Arpe prosthesis for the basal thumb osteoarthritis]. / Résultats à plus de cinq ans du traitement de la rhizarthrose par la prothèse Arpe.

INTRODUCTION: The surgical gold standart treatment of the thumb osteoarthritis is the trapeziectomy with tendon interposition with ligament reconstruction. The trapeziometacarpal prosthesis is insufficiently assessed in literature. METHODS: Between 1994 and 2001, 43 trapeziometacarpal prosthesis Arpe were implanted by the same surgeon for isolated trapeziometacarpal degenerative osteoarthritis. The minimum follow-up is 5 years. 33 women and 2 men , average age 59,4-years, were operated after failure of conservative treatment. 7 patients were lost sight of (9 prosthesis) and 2 deaths (2 prosthesis). 26 other patients (32 prostheses) were examined by the author with an original revision questionnaire associated to the score of DASH. RESULTS: 7 revisions were necessary: 5 for loosening, 1 for premature dismemberment and 1 for recurrent partial dislocation. The survival of the prosthesis is 85% in 5 years. In the group of 25 prosthesis still implanted, there is no radiological sign of loosening, but in some cases a development of medial ossification. The average DASH score is 27,4/100. All the patients of this group are satisfied or very satisfied. CONCLUSION: The prosthesis Arpe is an effective option in this series for the treatment of the degenerative trapeziometacarpal arthritis but its radioclinical control is necessary for the first year.

[Revision of the ARPE prosthesis by the Jones procedure: a study of 6 cases and review of literature]. / Les reprises de prothèses trapezométacarpiennes ARPE par trapézectomie. Ligamentoplastie selon la technique de Jones: une étude homogène de six cas et revue de la littérature.

INTRODUCTION: The rate of failure of trapeziometacarpal prostheses increases with time for all types of prosthesis. Procedures for salvage are rarely detailed in the literature. MATERIAL AND METHODS: In a series of 43 prosthesis ARPE between 1994 and 2001, 7 revisions (16%) were necessary. Six were treated by trapeziectomy and interposition of the palmaris longus tendon according to the technique of F.E. Jones. The average follow-up was 51 months (9-120). The study contained 5 women and 1 man, all reviewed by the author and the outcome assessed using an original questionnaire. The average age at the time of the revision was 62 years. The revision was necessary on average after 34 months (1 month to 10 years). All the procedures (implantations and revisions) were performed by the same surgeon. RESULTS: The reason for the revision was loosening of the cup in 4 cases, excessive polyethylene wear in one case and premature dismantling for the last case. Ablation of the cup was straightforward but the extraction of the metacarpal side could still be difficult. For the revision, the Jones procedure did not present difficulties. Thumb function was satisfactory but force was slightly lower than on the opposite side. The scaphometacarpal height was always reduced (34,5% on average). Aesthetically, 2 patients were disappointed and preferred their thumb with prosthesis in place. DISCUSSION AND CONCLUSION: Reports in the literature quote a revision rate of 15% after a follow-up of 4 years. Hence revisions will be more and more frequent in the future. Trapeziectomy with tendinous interposition is an excellent technique of revision because it is reliable medium-term and gives patient satisfaction in terms of thumb function. The results of this technique of revision should be compared with the same technique used as the primary procedure.

Long-term results of Letournel scapulothoracic fusion in facioscapulohumeral muscular dystrophy: A retrospective study of eight cases.

BACKGROUND: The aim of this study was to evaluate long-term radio-clinical outcome in scapulothoracic fusion using the Letournel technique (where the fourth rib is passed through the wing of the scapula and cerclage wires are tightened to the two ribs below) for patients suffering from facioscapulohumeral muscular dystrophy (FSHMD), a degenerative pathology affecting scapula-stabilizing muscles, leading to scapular winging, shoulder pain and restricted shoulder abduction and flexion, despite a functional deltoid muscle. METHODS: This retrospective study, with an average follow-up of 14 years (168 months; σ=73 months), included four patients who underwent a bilateral procedure, one side after the other, with shoulder abduction and flexion gain as primary endpoints. RESULTS: Mean improvement in range of motion was 36° (σ=32°) in abduction and 40° (σ=44°) in flexion. Postoperatively, active abduction averaged 99° (σ=28°) and active flexion 110° (σ=45°). In one case, a 58 year-old patient, gain in motion was 50° for abduction and 60° for anterior elevation. In one patient, range of motion showed bilateral decrease due to the natural course of the FSHMD. No intraoperative complications were reported. DISCUSSION: The Letournel technique seems to be an effective long-term solution in FSHMD, without age limit. Improvements appear to be steady over time, the only long-term limitations being the natural course of the disease itself. LEVEL OF EVIDENCE: IV - retrospective case series.

Acute finger-tip infection: Management and treatment. A 103-case series.

INTRODUCTION: Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation. MATERIALS AND METHOD: One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16). RESULTS: Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth. DISCUSSION: Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.

Interest of the "compress test" in diagnosis of nerve injury in hand wounds.

INTRODUCTION: Hand wounds are a common cause of emergency department admission. Digital nerve lesions are found in 5% of palm wounds. Early diagnosis reduces the risk of morbidity, sequelae and litigation. Screening for digital nerve injury by the usual tests is difficult in an emergency context. We assessed the diagnostic value of the simple "compress test" to screen for pulp sensibility disorder and the factors that may influence the value of this examination, with a view to validating routine use. MATERIAL AND METHOD: A retrospective study included 821 palm wounds treated between January 2014 and May 2016. There were 605 male and 216 patients; mean age, 42.8 years (range: 18-90 years). The dominant hand was involved in 307 cases (37.4%). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the compress test were calculated. Diagnostic value was also calculated according to age, gender, affected digit, dominant side and examiner's experience. RESULTS: Clinical deficit was found in 412 cases (50.2%). A digital nerve lesion was found intraoperatively in 277 cases (33.6%). Test sensitivity was 87.3%, specificity 68.6%, positive predictive value 58.5%, negative predictive value 91.4%, positive likelihood ratio 2.78 and negative likelihood ratio 0.18. The test was more effective for thumb wounds and for examination by a junior surgeon. There were no differences according to injured side, innervation territory or gender. CONCLUSION: This clinical test is reliable, with very good negative predictive value and good sensitivity, allowing its use in routine clinical practice. Nevertheless, surgical exploration of deep palm injuries should remain the rule.

Peritrapezial osteoarthritis: Inter- and intraobserver reliability of the Allieu classification.

The Allieu classification takes into consideration the distal and proximal joints of the trapezium. Trapeziometacarpal (TMC) joint arthritis, TMC joint instability (TMI) and scapho-trapezio-trapezoid (STT) joint arthritis are considered independently, which better corresponds to the anatomical examinations. The aim of the study was to evaluate the inter- and intraobserver reliability of the Allieu classification of the peritrapezial arthritis. This was a prospective, single-center study performed from May to September 2016 with 30 cases of primary thumb osteoarthritis. Five raters scored the X-rays twice. In the Allieu classification, TMC arthritis is scored as "0" when the TMC joint is normal, "1" when the TMC joint space is <50% narrowed, "2" when the TMC joint space is >50% narrowed, "3" when the joint space is loose with advanced degenerative changes. TMI is scored as "0" for reducible subluxation, painful and unstable joint, "1" for advanced reducible subluxation, "2" for chronic subluxation <1/3 of the surface, "3" for chronic subluxation >1/3 of the surface. STT joint arthritis is scored as "0" for normal joint space, "1" for joint space narrowing <50%, "2" for important joint space narrowing and "3" for advanced degenerative changes with sclerotic subchondral bone changes. Inter- and intraobserver reliability was assessed using the weighted Cohen's kappa coefficient. Additional analyses were undertaken to determine the intraclass correlation coefficient (ICC) for the overall raters. The interobserver reliability was "moderate" to "substantial" for the TMC arthritis; "fair" to "substantial" for STT arthritis and "fair" to "substantial" for TMI. The intraobserver reliability was "moderate" to "excellent" for TMC arthritis (2 "excellent", 2 "substantial", 1 "moderate"); "fair" to "excellent" for the STT (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair") and "fair" to "excellent" for the TMI (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair"). The worst reliability, either for intra- or interobserver, was for TMI. The ICC for TMC arthritis was 0.67 (95%CI, 0.28-0.83); for STT it was 0.47 (95%CI, 0.15-0.66) and for TMI it was 0.30 (95%CI, 0.23-0.70), which is "fair". This study confirms a large variation in X-ray staging for peritrapezial arthritis. It shows that the Allieu classification is moderately reliable. However, the interobserver reliability was better for evaluating the TMC than the STT and worse for TMI. The classification for TMC and STT is simple to apply, based principally on the joint narrowing. The intraobserver is better than the interobserver reliability.

Lateral band translocation for swan-neck deformity: Outcomes of 41 digits after a mean follow-up of eight years.

BACKGROUND: Swan-neck deformity (SND) of the fingers can cause major functional impairment. The Zancolli-Tonkin procedure is a crossed dynamic tenodesis that prevents overextension of the proximal interphalangeal (PIP) joint and promotes extension of the distal interphalangeal (DIP) joint. We assessed the outcomes of this procedure in patients with SND due to various causes. HYPOTHESIS: The Zancolli-Tonkin procedure provides effective and stable correction of SND due not only to RA, but also to other conditions. PATIENTS AND METHODS: Consecutive patients managed at two centres between 2000 and 2013 were included. The causes of SND were inflammatory joint disease, trauma, iatrogenic events, and neurological disorders. The same operative technique was used in all patients. RESULTS: Forty-one fingers in 14 patients were evaluated. After a mean follow-up of 8 years, all patients could harmoniously flex the operated fingers and none had recurrence of the deformity. At the PIP joints, mean active flexion was 86° (range: 40°-90°) and mean loss of extension was 15° (range: 0°-40°). At the DIP joints, mean active flexion was 65° (range: 0°-70°) and mean extension lag was 4° (range: 0°-30°). The mean visual analogue scale pain score was 1/10 (range: 0/10-8/10) and the mean patient satisfaction score was 7.5/10 (range: 4/10-10/10). DISCUSSION: The SND was corrected and the results were stable after 8 years in all cases. Advantages of the Zancolli-Tonkin procedure include limited invasiveness, with no need to harvest a distant tendon, and rapid active postoperative rehabilitation. The moderate excessive PIP joint flexion has no adverse impact on the overall functional outcome. The high level of patient satisfaction reflects the improvements in function. CONCLUSION: The Zancolli-Tonkin procedure is a simple and reliable technique that provides lasting correction of an incapacitating deformity associated with impaired overall hand function. LEVEL OF EVIDENCE: IV.

Intermediate term evaluation of the Eclypse distal radio-ulnar prosthesis for rheumatoid arthritis. A report of five cases.

HYPOTHESIS: Early medical management of rheumatoid arthritis with biotherapy has changed the traditional musculoskeletal damage from this disease. When the distal radio-ulnar joint (DRUJ) is involved, classic procedures may be inappropriate. We chose a hemi-arthroplasty of the DRUJ joint (Eclypse™) in patients with persistent synovitis and chondrolysis with a stable joint. The aim of this study was to assess the intermediate term results of this approach in these specific cases. MATERIALS AND METHODS: We report a retrospective study of 5 Eclypse arthropasties implanted between March 2005 and March 2011. There were 4 women and 1 man, mean age: 58.4years old (54-62) with RA that had been present for 21.6years (15-33). This hemi-arthroplasty replaced the ulnar head with a pyrocarbon component. Patients were evaluated by an independent observer for pain by VAS, range of motion, grip strength in the neutral position by Jamar dynamometer, pronation and supination strengths with a pronosupinator, DASH score and wrist X-rays. RESULTS: One patient was lost to follow-up and the 4 others underwent a follow-up evaluation at 64 months (43-90). There were no intra-operative or postoperative complications. The pain score at the final follow-up was 1.5/10 (0-4), pronation was 70° (60-80) and supination was 80° (80-80). Grip strength was 148% compared to the contralateral side (73-200%). Pronation and supination strengths were 1.7kg (1.5-2) and 2.1kg (2-2.5) respectively. The DASH score was 55.9 points (42.6 to 79.3). X-rays did not show any changes in the ulnar notch. CONCLUSION: This distal radio-ulnar arthroplasty is less invasive and preserves the bone and ligaments. Clinical results are rapid, remain stable over time and are well tolerated. This arthroplasty, which was initially developed for osteoarthritis and traumatic lesions of the DRUJ, is promising for specific cases of rheumatoid arthritis.

Cross-finger flap for reconstruction of fingertip amputations: Long-term results.

UNLABELLED: Fingertip amputations are severe hand injuries. Their treatment must restore the sensation and metabolic activity needed for pain-free finger function. The cross-finger flap (CFF) can be used for this purpose. The goal of this study was to assess the long-term clinical outcome following use of this flap. METHODS: This was a retrospective analysis of 28 patients operated because of fingertip amputation: 16 type 3, 8 type 2 and 4 type 4. The CFF was harvested from an adjacent finger on the dorsal side of the middle phalanx down to the epitenon. A dorsopalmar hinge was preserved to ensure vascularisation. The CFF was divided an average of 18.7 days later. The following parameters were evaluated: pulp volume (injured compared to contralateral finger), presence of neuroma, occurrence of complications (necrosis, infection, and donor site morbidity), cold discomfort, static and tactile discrimination, and patient satisfaction (0 to 10 on VAS). RESULTS: The average follow-up was 19.7 years; 22 patients (78.6%) were re-examined in person or contacted by telephone. The average healthy pulp to reconstructed pulp ratio was 1.03. No postoperative complications such as neuroma were found. Cold sensitivity was present in 7 patients. The flap was re-sensitised in all the patients. There was no donor site morbidity. The average patient satisfaction score was 9 (range 8-10). CONCLUSIONS: Over the long-term, use of the CFF results in nearly normal fingertip metabolism, no complications and good distal sensitivity without pain or neuromas. This is a simple, reliable, long-lasting reconstruction technique. LEVEL OF EVIDENCE: IV.

[Botulinum toxin injections and hypertonic upper limbs. Which functional results?]. / Membres supérieurs fonctionnels hypertoniques et toxine botulique. Quels résultats fonctionnels?

OBJECTIVES: To assess the efficacy of botulinum toxin injections for hypertonic upper limbs in patients with residual motricity that allows a functional use of the hand. METHODS: Patients were seen between February 2000 and November 2002, before and after botulinum toxin injections for hypertonic upper limbs due to upper motor neuron syndrome. All patients had voluntary motricity in fingers and wrist extensors. Impairment (range of motion, spasticity [Ashworth's scale]), pain (10 centimeters visual analog scale) prehension (400-point measure) and patients' satisfaction were recorded. Two or three functional goals were predefined. Patients were injected after locating the target area with neurostimulation. The aim of the injections was functional improvement. RESULTS: Eight patients were included. After injections, mean pain score decreased by 3.4 points; mean spasticity decreased by 1.0; and prehension improved, especially for bimanual functions. Three-quarters of the functional goals were reached. Optimal efficacy required repeated injections, with modification of muscle targets and doses. CONCLUSION: Botulinum toxin injection is efficient for impairment, pain and prehension in hypertonic upper limbs, even if the hypertonic hand is still the "nondominant" hand. Motricity in antagonist muscles is essential for functional improvement, and the assessment must include bimanual tasks. Intrinsic as well as extrinsic muscles must be injected and a neurostimulator used for forearm muscles. Comparative studies are required to define more clearly the place of this treatment among medical and surgical treatments of spasticity.

[Reorientation of the distal radial articular surface in Madelung's deformity by a reversed cuneiform osteotomy]. / Réorientation de la glène radiale dans la déformation de Madelung par ostéotomie cunéiforme avec retournement.

A technique of cuneiform osteotomy of the distal end of the radius is presented. It was used in three female patients with Madelung's deformity (two bilateral cases and one unilateral case). A wedge of bone was harvested in situ from the metaphysis, then returned and replaced in situ. This technique, performed through the Henry's approach, combines closing wedge osteotomy on the longer radial cortices with opening wedge osteotomy on the shorter radial cortices. The biplane osteotomy, which provides the bony wedge, involves the entire width of the metaphysis and is performed with an oscillating saw. Once the wedge is reversed and replaced, stabilization is obtained with an anterior plate. In all five cases the forward subluxation of the carpus was reduced as well as the distal radioulnar dislocation through the backward projection of the epiphysis. The reversed cuneiform osteotomy brings new possibilities of reorienting the radial articular surface and its technical mastery allows for accurate correction of severe deformities.

Dellon's anterior submuscular transposition of the ulnar nerve: Retrospective study of 82 operated patients with 11.5 years' follow-up.

Anterior submuscular transposition of the ulnar nerve described by Dellon can solve the dynamic component of cubital tunnel syndrome at the elbow. We carried out a retrospective, single-surgeon study. The McGowan scale as modified by Goldberg (MG) was used preoperatively and at the final assessment; the QuickDASH was completed at the final assessment. The cohort comprised of 82 patients (38 females, 44 males) with a mean age of 61.2 years (37-92). The preoperative MG grade was: stage I (52%), IIA (28%), IIB (16%), III (4%). Three postoperative complications (3.5%) were recorded: two hematomas that did not require surgical revision and one case of elbow stiffness that resolved with physical therapy. Mean follow-up was 11.1 years (11-12). We identified 5 cases of confirmed recurrences (5.9%), 7 of secondary deterioration (8.5%) and 3 of initially poor result (3.5%). Sixty-six patients (86%) considered themselves cured at the final assessment. The MG scale at the last follow-up was: stage 0 (85.5%), I (9%), IIA (5%), III (0%). The QuickDASH was 11.88 (11-16). Mean time to recurrence was 6.3 years (1.5-10). Dellon's anterior submuscular transposition can be considered a reliable procedure. Eighty-six percent of patients were cured and 6% recurrence rate was noted. However, this is a demanding procedure.

"Butterfly flap": The retinaculum to the rescue of the extensors.

Extensor digitorum tendon (EDT) tear in the wrist is frequently associated with inflammation (rheumatoid arthritis, chondrocalcinosis) or distal radio-ulnar osteoarthritis. EDT protection and repair is often hampered by poor tissue trophicity and associated procedures. We describe an extensor retinaculum (ER) plasty, protecting and recentering the EDTs. The procedure consists in raising the ER on either side of Lister's tubercle so as to create a strap protecting and recentering the 4th, 5th and 6th compartment EDTs; the 2nd and 3rd compartment EDTs are left free on the lateral side of Lister's tubercle. This "butterfly plasty" provides solid and effective protection of the EDTs in an often fragile pathologic context. It creates a glide space, stabilizing EDTs and wrist. LEVEL IV: Retrospective series.

[Harris and Galante non-cemented total hip prosthesis. 1st results]. / La prothèse totale de hanche sans ciment de Harris et Galante. Premiers résultats.

Amongst the various models of total hip prosthesis available on the market, the Harris and Galante non-cemented implant constitutes an attractive alternative. The authors report their preliminary experience on the basis of a limited series (77 hips) and a follow-up of 6 to 30 months. The hemispherical acetabular prosthesis, which is very easy to use, induces a local reaction in about 10% of cases. The femoral pivot, inserted by means of a very sophisticated apparatus, is more frequently responsible for local reactions (4 circumferential rings, 2 of which were asymptomatic, and 24 partial rings particularly in Gruen's zone 1). Although the preliminary results of this short series appear to be encouraging (59 operated patients out of 63 were scored as D5 - D6), a longer follow-up is nevertheless essential.