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.

Iatrogenic hand trauma in institutionalized brain-injured patients: About 2 cases.

The objective of this work was to draw the attention of caretakers for institutionalized brain-injured patients to the risk of iatrogenic trauma associated with improper manipulation of the fingers during hand opening for grooming. Two clinical cases of chronic open dislocation of the thumb and the fifth finger in institutionalized brain-injured patients were reviewed. Interrogation of the patients and their relatives did not reveal either the date or the mechanism of the injury. In the light of these two cases, it appears that better training of caretakers should make it possible to avoid iatrogenic trauma during hygiene care of institutionalized brain-injured patients.

Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique.

The aim of this work was to analyze the results of a percutaneous drainage technique with 2 catheters during surgical treatment of phlegmons of the finger flexor tendon sheath. Our series included 32 patients with a phlegmon of flexor tendon sheaths, including 19 men and 13 women, mean age 43.4years. The first 16 patients (group I) were treated by a conventional open technique for the lavage and drainage of the affected tendon sheath. The last 16 (group II) were treated by an ultrasound-guided percutaneous lavage technique with 2 catheters: one proximal and one distal. In the case of impermeability of the digital canal, conversion by open technique was carried out. In group II, the ultrasound-guided percutaneous lavage was 5 times successful. Failure of the proximal catheter alone was noted once, whereas failure of the distal catheter alone was noted 7 times. The failure of both catheters was noted 3 times. At a mean follow-up of 19.7 days, mean handgrip strength was 56.5% compared to the contralateral side in group I and 82% in group II (P<0.05). However, there was no significant difference for pain, QuickDASH, total active mobility between group I and group II. Pain was at 1.4/10 for group I and 1.4/10 for group II. QuickDASH was measured at 27/100 for group I and 22.27/100 for group II. Total active mobility was 227° for group I and 243° for group II. In conclusion, surgical treatment of the phlegmons of the finger flexor tendon sheath with an ultrasound-guided percutaneous lavage technique gives significantly better short-term grip strength than the conventional open technique.

Comparison between isotropic linear-elastic law and isotropic hyperelastic law in the finite element modeling of the brachial plexus.

Augmented reality could help the identification of nerve structures in brachial plexus surgery. The goal of this study was to determine which law of mechanical behavior was more adapted by comparing the results of Hooke's isotropic linear elastic law to those of Ogden's isotropic hyperelastic law, applied to a biomechanical model of the brachial plexus. A model of finite elements was created using the ABAQUS® from a 3D model of the brachial plexus acquired by segmentation and meshing of MRI images at 0°, 45° and 135° of shoulder abduction of a healthy subject. The offset between the reconstructed model and the deformed model was evaluated quantitatively by the Hausdorff distance and qualitatively by the identification of 3 anatomical landmarks. In every case the Hausdorff distance was shorter with Ogden's law compared to Hooke's law. On a qualitative aspect, the model deformed by Ogden's law followed the concavity of the reconstructed model whereas the model deformed by Hooke's law remained convex. In conclusion, the results of this study demonstrate that the behavior of Ogden's isotropic hyperelastic mechanical model was more adapted to the modeling of the deformations of the brachial plexus.

Analysis of the modifications of MRI signal of the brachial plexus of rats: Comparative study before and after freezing/thawing.

The aim of this study was to compare the MRI signal of the brachial plexus and surrounding muscles before and after freezing/thawing on a murine model. A first MRI going through the brachial plexuses of 5 healthy Wistar rats was performed immediately post-mortem. A second MRI was performed after freezing at -30°C and then thawing at 20°C for 24hours. All MRI images were segmented to make nerve and muscular structures appear and calculate the average intensity of the MRI signal using the program ImageJ. The average nerve and muscular MRI signals were compared before and after freezing/thawing and rated in grayscale units between 0 and 255. The average intensity of the MRI signal of nerve structures was 40.315 grayscale units before freezing and 31.943 after freezing/thawing. The average intensity of the MRI signal of muscular structures was 25.44 grayscale units before freezing and 35.710 after freezing/thawing. Our results have shown that the intensity of the MRI signal of the brachial plexus was higher before freezing/thawing. The intensity of the MRI signal of muscles was lower than the intensity of the brachial plexus before freezing/thawing and higher after freezing/thawing in muscles than in brachial plexus. The MRI could be used in clinical practice to monitor the reinnervation after frozen nerve allografts.

Technical feasibility of robot-assisted minimally-invasive neurolysis of the lateral cutaneous nerve of thigh: About a case.

To limit the risk of iatrogenic neuroma and recurrence after surgical treatment of meralgia paresthetica, some authors have recently developed a technique of endoscopic neurolysis of the lateral cutaneous nerve of thigh (LCNT) below the level of the inguinal ligament. We report the case of a robot-assisted endoscopic technique underneath the inguinal ligament. A 62-year-old patient suffering of idiopathic meralgia paresthetica for the past 18 months received a Da Vinci robot-assisted minimally-invasive 10cm long neurolysis, of which 1/3 was situated above the level of the inguinal ligament and 2/3 below it. The patient was discharged the following day without complications. At 6-months follow-up the pain was rated 0/10 compared to 5/10 pre-operatively. Robot-assisted endoscopic neurolysis of the LCNT retains the advantages of conventional endoscopy and enables to approach the nerve in the most frequently compressed zone underneath the inguinal ligament. The three-dimensional view offered by robotic surgery facilitates the dissection. The superiority of this technique remains to be demonstrated by comparing it to conventional techniques.

Enlargement of the flexor pulleys by an omega plasty: A study comparing the release of one or both sides of the A2 and/or A4 pulley.

PURPOSE: The omega plasty on one side of the A2 and/or A4 pulley improves the gliding of repaired flexor tendons in zone II. The purpose of this study was whether or not the enlargement of the digital channel was better after the release of one or both sides of each pulley. METHODS: In fresh cadavers, the technique was to first disinsert the ulnar attachments of the A2 and A4 pulleys and then the radial insertions. An ultrasound was used to measure the large axis, the circumference, and the cross-sectional surface of each of A2 and A4 pulleys before release, after ulnar release and after radial release. RESULTS: The release of the A2 pulley reduces the risk of conflict in the sutured flexor tendons in the digital channel. The release of the A4 pulley seems less effective than that of A2. The release of the two pulleys reduces the risk of conflict in one sutured zone of the flexor tendons in the digital channel. CONCLUSION: In all, if there is a conflict between the flexor tendons sutured opposite A2, we recommend an omega plasty on the two sides of the pulley. If the conflict appears opposite A4, we recommend the plasty of the two sides of A4 and A2.

[The abdominal drop flap]. / Le lambeau de recul abdominal.

The skin between the mastectomy scar and the future infra-mammary fold may be managed in different ways in delayed breast reconstruction using a DIEP (deep inferior epigastric perforator). Conserving this skin and positioning the flap skin paddle in the middle of the breast usually highlights skin color disparity because of two visible transition zones. Resection of the entire skin under the scar may be more aesthetic but limits direct closure possibility in case of flap failure. In order to benefit from both aesthetic result and safe surgical method, we propose the abdominal drop flap. The inferior thoracic skin flap is detached from the thoracic wall beyond the future infra-mammary fold, preserved and pushed under the breast.

Distal radius fixation through a mini-invasive approach of 15 mm. Part 1: feasibility study.

The aim of this study was to determine the feasibility of a mini-approach for distal radius volar plating. A 15-mm incision was made in 11 cadaver wrists. A 41 mm length and 24 mm width plate was placed deep to the pronator quadratus then fixed using 2 K-wires. The 2 central epiphyseal screws were placed before pin removal, the lateral screws followed and finally the proximal ones. The number of control views needed was on average 1.9 mm, and the position of the plate was good in 10 cases and average in 1 case. The size of the incision after the operation was on average 16.3 mm. No complications were found. Our results show that volar plate fixation of distal radius fracture is feasible through a 15 mm approach. This approach is esthetic, respects noble structures and facilitates reduction due to ligamentotaxis.

Active multilayered capsules for in vivo bone formation.

Interest in the development of new sources of transplantable materials for the treatment of injury or disease has led to the convergence of tissue engineering with stem cell technology. Bone and joint disorders are expected to benefit from this new technology because of the low self-regenerating capacity of bone matrix secreting cells. Herein, the differentiation of stem cells to bone cells using active multilayered capsules is presented. The capsules are composed of poly-L-glutamic acid and poly-L-lysine with active growth factors embedded into the multilayered film. The bone induction from these active capsules incubated with embryonic stem cells was demonstrated in vitro. Herein, we report the unique demonstration of a multilayered capsule-based delivery system for inducing bone formation in vivo. This strategy is an alternative approach for in vivo bone formation. Strategies using simple chemistry to control complex biological processes would be particularly powerful, as they make production of therapeutic materials simpler and more easily controlled.

Immobilization protocols following trapeziectomy for osteoarthritis of the thumb: 2 weeks versus 4 weeks.

We compared the clinical outcomes of post-trapeziectomy protocols according to their duration. The main hypothesis was that there would be no significant difference in postoperative function whether immobilization duration was 2 or 4 weeks. The secondary hypotheses were that there would be no significant difference in postoperative pain, motion, or strength. 40 trapeziectomies were reviewed. Two weeks' postoperative commissural immobilization was systematic. Patients were then divided in two groups. For the first 20 patients (group I), immobilization stopped at 2 weeks. For the next 20 patients (group II) it was replaced by a splint for further 2 weeks. We compared mean pre- and post-operative (10-20 weeks) function (QuickDASH score), pain (visual analog scale - VAS), thumb opposition (Kapandji score) and strength (palmar pinch test) between the two groups. There was no significant difference between groups in postoperative values or in pre- to post-operative progression. The main hypothesis was confirmed: there was no significant difference in the postoperative function whether the immobilization was for 2 or 4 weeks. The secondary hypotheses regarding postoperative pain, motion and strength were also confirmed.

[A trick to improve the technique of the IntraVascular Stent (IVaS): "Clip Stent"]. / Une astuce pour améliorer la technique du stent intravasculaire (IVaS) : le "Clip Stent".

The infra-millimetre vessels are difficult to suture, because the placement of forceps in the lumen is delicate and threads often cross the walls. The technique of the IntraVascular Stent (IVaS), developed to remedy it, did not make the proof of its superiority. The purpose of this study was to analyze the results of a variant, the Clip Stent. Our series included two groups of 10 rats. In group I, the artery of the tail was anastomosed by threads of nylon 10/0. In group II, the artery was anastomosed according to the technique of Clip Stent including three stages: introduction of a monothread of polypropylene 6/0, anastomosis by threads of nylon 10/0, ablation of the Clip Stent and the closure of possible leaks. The assessment consisted in measuring the time of anastomosis, in counting the number of separate threads and leaks, and in testing the permeability. The time of anastomosis was longer 12 minutes in the group II. The number of points by anastomosis was 6.5 in the group I and of 5.5 in the group II. The permeability was 90% in two groups. The Clip Stent is faster than the IVaS. It is useless to realize vascular threads of the lumen before the introduction of the stent. Once the stent in position, it cannot traumatize the intima and its migration is impossible. Contrary to the IVaS, the Clip Stent allows to realize the last threads stent in position, by releasing the tourniquet. The ablation is safe. Its superiority to the conventional methods remains to demonstrate by improving its introduction in the lumen.

Risk of septic spread during surgical management of digital flexor tendon sheath phlegmon: Exsanguination by mechanical compression versus simple elevation.

This study aimed to demonstrate that there was no risk of extension of infection in performing mechanical exsanguination before inflating the tourniquet for surgical treatment of digital flexor tendon sheath phlegmon. The series comprised 96 patients, with a mean age of 47 years (range, 18-87 years) and 37 women. Group I included 47 patients in whom exsanguination was performed with a Velpeau band before inflating the pneumatic tourniquet at the root of the limb. In Group II, which included 49 patients, the tourniquet was inflated after simple elevation of the limb. Six patients underwent revision surgery for recurrence or osteoarticular complications: 4 (8.5%) in Group I and 2 (4.1%) in Group II, the difference between two groups being non-significant (p = 0.6378). In conclusion, mechanical exsanguination before inflating the tourniquet did not incur risk of complications in surgical management of digital flexor tendon sheath phlegmon.

Revision surgery for carpal tunnel syndrome: a retrospective study comparing the combination of Canaletto® and Dynavisc® gel versus Dynavisc® gel alone.

The aim of this study was to assess the value of using a Canaletto® implant in combination with a gel composed of carboxymethylcellulose and polyethylene oxide in the surgical treatment of recurrent carpal tunnel syndrome (CTS). The case series included 31 patients with 32 hands operated for the second time for recurrent (22 cases) or recalcitrant (9 cases) CTS by neurolysis. The average patient age was 62 years. Dynavisc® gel alone was applied around the median nerve in the first 16 cases (Group I). The Canaletto® implant combined with Dynavisc® gel was used in the last 16 cases (group II). With an average follow up of 8 months (for group I) and 11 months (for group II), the pre/postoperative variation in pain assessed with a visual analog scale was 1.38/10 (group I) and 2.04/10 (group II), the QuickDASH score was 20.1/100 (Group I) and 20.48/100 (Group II), grip strength was 8% (Group I) and 20% (Group II), sensory nerve conduction speed was 23.20 m/s (group I) and 15.51 m/s (group II) and distal motor latency was 1.55 m/s (group I) and 1.21 m/s (group II). Ten patients recovered from hypoesthesia in both groups, 6 patients in group I and 2 patients in group II regained good trophicity of their superficial thenar muscles. Two patients from group II had not improved clinically although their electromyography had become normal. One patient from group II suffered a postoperative infection that required removal of the Canaletto® implant. He subsequently improved slightly. Our study found that for recurrent or recalcitrant CTS, the combination of Dynavisc® anti-adhesion gel around the median nerve and a Canaletto implant® after neurolysis results in outcomes that are as good as Dynavisc® alone, with a significant improvement of the QuickDASH score without the Canaletto®. In conclusion, the use of Dynavisc® gel alone around the median nerve after neurolysis seems to be as effective as other techniques described in literature but less invasive or time-consuming, and not associated with donor site morbidity such as the flexor tendon sheath.

Organization of outpatient consultations at a hand surgery department in a French university hospital during the COVID-19 lockdown.

The COVID-19 health crisis has greatly impacted the organization of outpatient consultations, especially in hand surgery. Five reorganization stages were described during the crisis (from week 11 to week 21 in 2020): preparatory stage, 1st organizational stage, wait-and-see stage, 2nd organizational stage, and progressive return stage. The number of patients seen on-site decreased 64% in 2020 compared to 2019, while 78% of consultations were canceled. The logistics (teleconsultation, dedicated COVID-19 patient pathways) and human resources (sick leave, telework, reassignment to other departments) were adapted to ensure that patients who are usually seen in our hand surgery department received adequate care.

Flexor tendon complications in distal radius fractures treated with volar rim locking plates.

Volar locking plates used for treating distal radius fractures can damage the flexor tendon. Fractures distal to the watershed line can be fixed using volar rim locking plates. The aim of our study was to report the incidence of flexor tendon lesions when using these plates. Our case series included 15 patients (7 women, 8 men), aged 59 years on average (23-88) who underwent distal radius fixation using a volar rim plate (Extradistale®, Newclip Technics™, Haute Goulaine, France). Eight patients had complications: seven cases of synovitis treated by synovectomy with a satisfactory final outcome, 10 cases of partial tendon ruptures treated by synovectomy and tendon repair in two cases, and five cases of complete rupture that were not repaired at the patient's requests. Our working hypothesis was not verified as we found flexor tendon complications in half our patients. When the fracture is distal to the watershed line, we recommend removing the plate after bone healing, never after the 3rd month postoperative.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating.

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

Treatment of complex proximal interphalangeal joint fractures using a new dynamic external fixator: 15 cases.

The management of proximal interphalangeal joint fractures of the fingers is difficult. Dynamic traction splinting systems are cumbersome and the Suzuki fixator does not prevent secondary fracture displacement. Fifteen cases were treated with a new dynamic external fixator with distraction, the Ligamentotaxor. In two cases, additional fixation was required with a screw. After 10 months, grip strength scored 85.7% compared with the contralateral hand, flexion achieved 76.3 degrees and the extension deficit was 19.6 degrees . The visual analogical scale pain level (VAS) was 1.9 and the Quick DASH score totalled 16.9. Revision treatment was needed for sepsis for one patient. A case of secondary fracture displacement was corrected in the outpatient clinic. Consolidation was achieved in all cases. In conclusion, despite imperfect outcomes for these complex fractures, we believe that the Ligamentotaxor technique is useful.

Benefits of using the "Micro-Clock" to evaluate the acquisition and maintenance of microsurgery skills.

This study was done using an educational tool called the "Micro-Clock", which was inspired by Chan's "round-the-clock" training model. The Micro-Clock consisted of a surgical sponge on which 12 sewing needles were configured in the shape of a clock. The subjects were asked to thread a small suture through the eyelets as quickly as possible. Steadiness and instrument manipulation were evaluated during each trial and graded from 1 to 3. The execution time was measured in seconds. Fifteen instructors did the Micro-Clock test once in order to validate this tool's ability to assess the skills of qualified microsurgeons. Next, nine students, who were enrolled in a microsurgery diploma program, did the test nine times during the program to measure their progression and to evaluate their mastery and execution speed. There was no significant differences among the three instructor sub-groups (residents, assistants and senior surgeons) in their steadiness, instrument manipulation and execution time. When the students performed the Micro-Clock test, there was a significant improvement in movement fluidity as well as the execution time between the first and ninth test. Nevertheless, the execution time did not improve further after the fourth test. The Micro-Clock is a useful and reliable tool for teaching microsurgery skills and testing the maintenance of skills in qualified microsurgeons.

Revision surgery in carpal tunnel syndrome: a retrospective study comparing the Canaletto® device alone versus a combination of Canaletto® and Dynavisc® gel.

The aim of our study was to demonstrate the benefits of combining the Canaletto® implant with carboxymethylcellulose/polyethylene oxide gel in the surgical treatment of carpal tunnel syndrome (CTS) recurrences. Our case series included 39 patients (40 hands, one bilateral case) who underwent revision surgery for recurrent CTS (28 cases) or resistant CTS (12 cases). The mean age of the patients was 56 years. The Canaletto® only was implanted in the first 21 cases (group I). In the following 19 cases (group II), Dynavisc® gel was added to the protocol and applied around the median nerve when the Canaletto® was implanted. At 12 months' follow-up (group I) and 11 months' follow-up (group II), the pre-versus post-operative difference between the average values of the DN4 neuropathic Pain Score was 0.55/10 in group I and 2.25/10 in group II; the Pain Score was 2.23/10 (in group I) and 2.52/10 (in group II); the Quick DASH Score was 18.98/100 (group I) and 19.06/100 (in group II); the hand grip strength was 19.55% (group I) and 28.53% (group II); the sensory nerve conduction velocity was 8.67 m/s (group I) and 10.27 m/s (group II); the distal motor latency was 1.05 m/s (group I) and 1.75 m/s (group II). Nine patients recovered from hypoesthesia in both groups, 5 patients regained satisfactory trophism of the thenar muscles in group I and 3 patients in group II. No improvement whatsoever was noted in 2 patients in group II, despite the electromyogram being normal. One patient from group II suffered an infection that required revision surgery to remove the Canaletto®; this led to a moderate improvement. Our results show that when resistant or recurrent CTS is diagnosed, the combined treatment of an anti-adhesion gel such as Dynavics® around the median nerve with the Canaletto® implant after performing secondary neurolysis leads to satisfactory post-operative outcomes. Compared to other techniques described in the current literature, our technique is less invasive, quicker and associated with minimal morbidity of the surgical site.