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.

[Telemedicine and hand injuries: a feasibility study]. / Télémédecine et urgences de la main: étude de faisabilité.

In France, we count 1,400,000 hand injuries per year. Only 20% are taken care by hand surgeons. In these 20% many of injuries can be healed by non specific centres. Among the 80% remaining injuries, many of complex injuries should be taken care by specialised centres. It is advisable to get a specialised point of view despite the distance. The purpose of this work is to study the feasibility of telediagnosis in hand emergencies. The material contained a computer, a camera and a website which access needed a password. The physician in emergency room built up the e-medical file which can be referred by the expert to give his mind. The agreement of the patients was sought and all the data were unnamed. One hundred and twenty-nine e-medical files were created from a local general hospital. Sixty-six patients had wound injuries and 63 osteo-articular injuries. Sex-ratio was 3.8 and age average was 33 years old. Four hundred and sixty pictures and four movies were stored. The average of duration of tele-expert response was 7 h. Our results underline the great part which can be played by telemedicine in hand emergencies orientations.

Arthroscopic treatment of scaphoid nonunion with humpback deformity and DISI with corticocancellous bone grafting: Technical note.

For two decades, scaphoid nonunion has been treated arthroscopically. However, compressed cancellous bone graft does not have the same mechanical properties as corticocancellous bone graft for reducing the scaphoid humpback deformity and DISI tilt. Here, we describe an arthroscopic technique to treat Alnot stage IIB scaphoid nonunion. We treated a 27-year-old male patient for scaphoid waist nonunion with humpback deformity and DISI. A 8×8×10 mm cylindrical corticocancellous bone graft was harvested from the dorsal aspect of the radius using a single-use osteochondral autograft transfer system (OATS®, Arthrex Inc., Naples, USA). It was inserted in the nonunion site through an arthroscopic volar approach. Bone union was obtained at 3 months with lasting correction of the scaphoid humpback deformity and DISI. The functional result at 6 months was excellent. There were no complications. Scaphoid nonunion with humpback deformity and DISI may be treated arthroscopically with a corticocancellous bone graft.

Telemicrosurgery: a feasibility study in a rat model.

Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S (Intuitive Surgical) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operator's pronosupination amplitude was 360 degrees . Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice.

Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study.

Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist.

Rotational stability test for the diagnosis of radial collateral ligament rupture in the fingers: Anatomical study.

Diagnosing rupture of the radial collateral ligament (RCL) of the finger metacarpophalangeal (MCP) joints is difficult. The aim of this cadaver study was to validate a rotational test for the MCP after RCL transection. With the MCP and proximal interphalangeal joints in flexion, rotation along the axis of the proximal phalanx was applied through an extended distal interphalangeal joint to 36 cadaver fingers. Each finger's pulp described an arc of pronation and supination that was noted on the palm. The test was repeated three times: before transection, after transection of the proper collateral ligament (CL) and after transection of both the proper and accessory CLs. Rotational arcs were measured in pronation and supination. Mean length of the pronation arc after transection of the main RCL was 17.53mm, while it was only 12.41mm before transection for the supination arc. Mean length of the pronation arc after transection of both CLs was 22.83mm compared to only 11.93mm before transection. Our results show a significant difference in pronation stability of the MCP joint after transection of the RCL proper. We can conclude that this rotational stability test is a valid test for diagnosing RCL rupture in MCP joints.

[Pleomorphic adenoma of deep lobe of the parotid gland]. / Adenoma pleomorfo gigante de lóbulo profundo de la parótida: a propósito de un caso.

Parapharyngeal space tumors are rare. Salivary neoplasms being the most frequent ones. The important volume they can reach, their silent character, and the complex anatomic relationships of this area makes their surgical resection difficult. This report describes a case of a pleomorphic adenoma in the deep lobe of the parotid gland presented like a parapharyngeal mass, and its diagnosis and treatment.

Inside-out method to develop volar arthroscopic portals of the wrist in cadaver specimens.

Three direct volar portals for wrist arthroscopy have been described previously: two radiocarpal and one midcarpal. The aim of this study was to systematically describe four volar arthroscopic portals through minimally invasive incisions using an inside-out approach from known dorsal portals. Four volar arthroscopic wrist portals were studied on six hand specimens using an inside-out technique: a radial radiocarpal approach (RRCA), an ulnar radiocarpal approach (URCA), a radial midcarpal approach (RMCA) and an ulnar midcarpal approach (UMCA). Each volar approach corresponded to a dorsal approach: the 3/4 portal for RRCA, 4/5 portal for URCA, dorsal radial midcarpal approach for RMCA, and dorsal ulnar midcarpal approach for UMCA. The average range of motion of the scope through the RRCA was 65° in radial deviation and 72° in ulnar deviation; through the URCA it was 62° in radial deviation and 64° in ulnar deviation; through the RMCA it was 62° in radial deviation and 60° in ulnar deviation, and through the UMCA it was 59° in radial deviation and 68° in radial deviation. No iatrogenic injuries to important anatomical structures were noted. Based on these results, it is possible to perform these four volar portals through an inside-out technique with incisions mirroring the dorsal portals. They were easy to perform, safe and should be useful in ligament or bony intracarpal repair indications.

[Influence of the nasogastric tube in the pathology of the maxillary sinus]. / Influencia de la sonda nasoesofágica en la patología del seno maxilar.

INTRODUCTION: Nasoesophageal tube (NT) is very often used by the ear, nose and throat specialists in head and neck oncological surgery. It is well known the irritative effect that it has on the nasosinusal mucosa. The aim of this study is to analyze the relationship between the use of the NT and the pathology of the maxillary sinuses. MATERIAL AND METHOD: The study was carried out in 25 patients treated in our department who had been fed by NT, after surgery. A plain sinus X-ray was performed in the pre-operatory period and a control radiograph in the post-operatory period, and the results have been analyzed. RESULTS AND CONCLUSIONS: No sinusitis had been observed whatever length of time the NT remained in situ.

Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases.

UNLABELLED: The rate of malunion after distal radius fractures is 25% after conservative treatment and 10% after surgery. Their main functional repercussion related to ulno-carpal conflict is loss of wrist motion. We report a retrospective clinical series of minimally invasive osteotomies. The series consisted of 9 cases of minimally invasive osteotomies with volar locking plate fixation. All osteotomies healed. The average pain was 5.3/10 preoperatively and 2.1/10 at last follow-up. The mean Quick DASH was 55.4/100 preoperatively and 24.24/100 at last follow-up. Compared to the opposite side, the average wrist flexion was 84.11%, the average wrist extension was 80.24%, the average pronation was 95.33% and the average supination was 93.9%. With similar results to those of the literature, our short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion. TYPE: Case-series. LEVEL OF EVIDENCE: IV.

Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: a series of 38 cases.

Regardless of the treatment used, 25 to 45% of scaphoid fractures do not heal. Open surgery compromises vascularization and destabilizes ligament attachments. The aim of this retrospective study was to assess the value of retrograde percutaneous screw fixation of Alnot stage IIA and IIB scaphoid non-union in Schernberg zones 2 to 4. This series included 38 patients with a mean age of 31 years. Based on the Alnot classification, there were 16 stage IIA non-unions (12 in zone 3 and 4 in zone 2 according to the Schernberg classification) and 22 stage IIB non-unions (9 in zone 3 and 13 in zone 2). The time elapsed between the initial trauma and the surgical treatment was 10 months on average. Percutaneous retrograde fixation was performed with a cannulated 2.7mm compression screw. At 25 months follow-up, 31 of the non-union cases had healed (81.6%), of which 14 were stage IIA (87.5%) and 17 were stage IIB (77.3%), after an average 6.3 months. Average pain was 1.6. The average Quick DASH was 17.3/100. Compared to the opposite side, the average range of motion was 84.8% in flexion, 84.7% in extension, 98.9% in pronation, 96.5% in supination, 96.8% in ulnar deviation and 86.4% in radial deviation. The grip strength was 80.4% of the contralateral side. Seven patients did not heal after screw fixation; four of them healed after additional electromagnetic stimulation and three after addition of a vascularized bone graft. Based on this study's results, stage IIA non-unions can heal with simple retrograde percutaneous screw fixation. The same procedure could be enough for stage IIB non-union cases, however we recommend adding a cancellous bone graft by arthroscopy. Open surgery procedures are preferred when percutaneous procedures have failed.

Metacarpophalangeal joint arthroscopy in the fingers other than the thumb: Retrospective comparison of horizontal versus vertical traction.

The goal of this study was to compare the advantages and disadvantages of horizontal versus vertical traction by reviewing a small series of metacarpophalangeal (MCP) joint arthroscopy in the fingers other than the thumb. Our series included eight patients operated with traction placed along the axis of the operated finger. In four cases, traction was applied horizontally and in the other four, it was applied vertically. Arthroscopy was performed using dorsomedial and dorsoradial portals. The fluoroscopy unit was placed either vertically or horizontally as required. The average duration of patient set-up was 17.75min in the horizontal traction group and 32min in the vertical traction group. The average tourniquet time was 56.75min in the horizontal traction group and 71min in the vertical traction group. Horizontal traction required an additional procedure that can potentially compromise surgical asepsis. Vertical traction was less comfortable for the surgeon and horizontal placement of the fluoroscope increased the risk of compromised asepsis. Overall, arthroscopy of the MCP joint of the fingers other than the thumb is an easy technique, indicated for trauma-related and chronic lesions, which may be best performed with horizontal traction.

Arteriovenous haemangioma of the pterygoid process. Report of a case.

Arteriovenous haemangioma is a benign tumor which in ear, nose and throat practice is generally found in the soft tissues of the oral cavity. Bone involvement is very uncommon. These lesions typically manifest themselves in infancy, with a tendency towards spontaneous resolution. The management options comprise simple observation, embolization or surgical removal--depending on the location of the tumour and its symptoms. A correct diagnosis is essential to ensure the adoption of adequate measures during surgery. The present case describes an exceptional location of arteriovenous hemangioma of the pterygoid process, and discusses the associated diagnostic and treatment problems.

[Inverted papilloma of paranasal sinuses. Our experience of 15 cases. Review of literature]. / Papilomas invertidos de fosas y senos paranasales. Nuestra experiencia a partir de 15 casos. Revisión de la bibliografia.

Fifteen cases of nasosinusal inverted papilloma treated in our department from 1994 to 2000 are reported. The most frequent initial symptom was unilateral nasal obstruction. Some others symptoms were rhinorrea, facial pain and self limited epistaxis. The most frequent surgical procedure performed was the paralateral rhinotomy with medial maxillectomy. The median average for the follow up was 28 months, being diagnosed one recurrence. The paralateral rhinotomy with a medial maxillectomy, under functional endoscopic nasosinusal techniques are being more and more used, decreasing the indications of open techniques.

[Intelligent system to perform a diagnostic protocol for lymphatic invasion in laryngeal cancer]. / Sistema inteligente para protocolizar el diagnóstico de invasión ganglionar en el cáncer de laringe.

Laryngeal carcinoma is the most frequent malignant tumour in head and neck. Node invasion is known to be one of the most important prognostic factors. The aim of this study has been to design an intelligent system to perform a diagnostic algorithm of metastasic neck nodes. 122 clinical reports of patients diagnosed of laryngeal carcinoma in our department have been reviewed. The compiled data have been: tumor site, T stage, N stage (clinical, after CT scan and post-surgery). The method used to design the intelligent system has been the ID3, which is able to generate a minimal decision tree. Palpation has been the variable that has given more information about node invasion. CT has proved to be more efficient in supraglottic tumours. ID3 method has shown to be useful in performing diagnostic algorithms, specially when the number of cases and diagnostic tests are high.

[An exceptional form of cranio-facial fibrous dysplasia: fibrous dysplasia of middle turbinate]. / Una forma excepcional de displasia fibrosa craneofacial: displasia fibrosa de cornete medio.

Fibrous dysplasia is a rare bone disease that can be misdiagnosed because of the slowness of its symptoms. Although it is a benign disease its clinical behaviour can be severe, with possibility of local growth and malignant degeneration into osteosarcoma. An uncommon case of fibrous dysplasia is reported, affecting only the middle turbinate. Diagnostic and therapeutic problems are discussed.

Minimally invasive surgery of distal radius fractures: a series of 20 cases using a 15mm anterior approach and arthroscopy.

UNLABELLED: This study reports the results of minimally invasive surgical treatment of distal radius fractures using a 15mm incision with arthroscopic assistance. This was a retrospective series of 20 distal radius fractures in young or middle-aged patients caused by high-energy trauma and/or with articular involvement. The surgical procedure included two stages: fixation using a locking plate and then arthroscopy. The incision for plating was always 15mm long. Arthroscopy was used to reduce osteochondral fragments in two cases and to suture and pin six scapholunate lesions. After a mean follow-up of 4.3 months, the mean pain score was 1.9, QuickDASH was 24.6 and the mobility and grip strength were at least 75% of the contralateral side. The mean palmar tilt was 8.8° and the mean radial inclination 20.7°. The radio-ulnar index was -1mm with no DISI and the scapholunate gap was 1.5mm. There were three cases of CRPS type I. Our results show that arthroscopy-assisted, minimally invasive surgery for distal radius fractures using a 15mm incision results in a scar with good cosmetics and allows for easy reduction and fixation, and management of articular and ligament lesions. Its indications must take into account the functional demands placed on the wrist by the patient, energy of the trauma and fracture type. LEVEL OF EVIDENCE: IV.

First metacarpal resurfacing with polyvinyl alcohol implant in osteoarthritis: preliminary study.

Osteoarthritis of first carpometacarpal (CMC) joint is a condition that is frequently encountered in hand surgery. If conservative treatment fails, several surgical procedures are available ranging from arthroscopic debridement to total joint arthroplasty. This study focuses on a new resurfacing technique for the base of the first metacarpal using a polyvinyl alcohol hydrogel implant. Our preliminary study found good clinical outcomes and no inflammatory reaction after a follow-up of 30 months. However prospective studies with a longer follow-up and more patient are needed to confirm these results.

Use of the Konnyaku Shirataki noodle as a low fidelity simulation training model for microvascular surgery in the operating theatre.

The aim of this study was to test the feasibility of a type of Japanese noodle, named "shirataki konnyaku", for microsurgery training in the operating room. Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: one on a model of a femoral artery of a rat (control) and one on a model of a konnyaku shirataki. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and tightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anatomosis was significantly higher in the control group. The number of stitches was similar in both groups. The patency of the anastomosis was significantly lower in the control group. The tightness (no leak) of the anastomosis was significantly higher in the control group. The "konnyaku shirataki" model could improve the teaching of microsurgery due to its availability, low cost and structural similarity to the animal model.