Innervation and vascular supply of the first dorsal interosseous muscle and palmar interosseous muscle of the index: An anatomic descriptive study.

INTRODUCTION: The first dorsal interosseous muscle (FDI) and palmar interosseous muscle of the index (P2I) are essential for the strength and mobility of the index finger. This study aims to describe the course of the deep branch of the ulnar nerve (DBUN) and the blood supply to these muscles. MATERIAL AND METHODS: An anatomical cadaver study was carried out with 14 upper limbs from fresh, non-embalmed cadavers. All limbs were filled with an equal amount, based on weight, of colored silicone and diluent that was combined and catalyzed with 5% curing agent. The location of the DBUN's termination was specified relative the carpometacarpal joint. Every artery supplying either muscle was identified and documented. RESULTS: The DBUN had a slightly convex path, distal to the hook of the hamate and penetrated the FDI muscle at an average 41% of the second metacarpal length. An average of 1.3 branches to the P2I and 2.6 branches to the FDI were found. Four artery pedicles coming from the deep palmar arch supply the FDI with an average of one consistent and exclusive pedicle to the FDI and three pedicles heading to the P2I. According to the classification of Mathes and Nahai, the FDI has a type 2 blood supply and the P2I has a type 3 blood supply. CONCLUSION: In-depth knowledge of the vascular network supplying the FDI and P2I muscles and the course of the DBUN is essential when the DBUN is damaged or when dissecting these muscles for index pollicization.

[Metacarpal shaft reconstruction using medial femoral condyle flap: A case report]. / Reconstruction diaphysaire métacarpienne par transfert osseux vascularisé de condyle fémoral interne : à propos d'un cas.

We report the technique applied to reconstruct a whole shaft defect of the 4th metacarpal bone in a 22-year-old women after aneurysmal bone cyst resection. Local invasion leads to possible poor revascularization possibilities, justifying the use of a vascularized bone transfer. Surgical procedure consisted in a 5-centimeter free medial femoral bone flap transfer. Two months after surgery, no after effect was found at donor site and bone consolidation was complete. Bone fixation allowed early active motion and a complete recovery of flexion-extension range was present 1 year after surgery. Free medial femoral condyle was described several times as a solution for metacarpal defects, in osseous or osteocutaneous versions, it represents a useful option in hand surgeons' armamentarium.

Partial medial second toe pulp free flap and dermal substitute with skin graft for salvage reconstruction of a complete skin envelope degloving of the small finger.

Skin envelope degloving of fingers are rare injuries that require rapid care and surgical treatment. Mostly caused by ring finger injuries, these traumas include bone, tendon and neurovascular pedicle damage. The authors present an unusual case of finger degloving limited exclusively to the skin envelope, without skeletal, tendinous or vascular lesion. This rare case of skin envelope degloving rendered microsurgical revascularization impossible. The authors report the results at 12 months following salvage reconstruction combining a partial second toe pulp free flap for the volar side and a dermal substitute with a thin skin graft for the dorsum.

Intercarpal arthrodesis: A systematic review.

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

Pollicization in the treatment of congenital severe hypoplasia and aplasia of the thumb: a systematic review.

Pollicization of the index is the treatment of choice for severe hypoplasia and aplasia of the thumb. After a historical overview, we present a systematic review of this procedure. The main steps of this procedure were reported by Dieter Buck-Gramcko in 1971 and are still relevant nowadays. Many refinements have been described over the last decades by different surgeons to address limitations related to bone stock, musculotendinous structures and skin incisions. However, considering the complexity of this procedure and the results in the literature, the functional and esthetic outcomes can still be improved thanks to basic research. Pollicization of the index is rarely done and is one of the most demanding surgical procedure in hand surgery.

[The free groin flap utility. About 19 cases]. / Intérêt du lambeau inguinal libre. À propos de 19 cas.

INTRODUCTION: The pedicled groin flap, well known for the hand resurfacing, has first been described by Mac Gregor in 1972. But the free groin flap is unpopular because of its short (5mm) and small artery (caliber 1,5 to 2mm) and a bulky aspect. The purpose of this study is to show its interest by weighing up the pros and cons of its advantages and of its disadvantages. PATIENTS AND METHODS: This study concerns 19 cases of free groin flap for posttraumatic reconstruction of limbs between 1994 and 2009. The patients including six children, were 10 males and nine females, ages from 4 to 50 years old. The size flap ranged from 4×10 to 15×25cm. We reported the indications, the wound's size, the postoperative complications and the quality of life. RESULTS: We observed one total necrosis and three partial necrosis. One debulking was generally required. CONCLUSION: The free groin flap has a lot of valuable qualities: a good vascularisation, allowing a big size flap (20×30cm), with direct closing of the donor site, in only one surgical installation, without sacrifying a muscle. The scar of the donor site is easily hidden by underwear. The flap's skin has good quality, without hair, and the antifibrotic effect of the fat permits a good tendinous sliding. Compared to the pedicled groin flap, this free technique enables the reconstruction of the lower limbs, while upper limbs are free, without weaning time. The functional and aesthetic result of the reconstruction is good and we think that for a microsurgical team, this reliable flap should be more chosen for the posttraumatic reconstruction of limbs.

Scaphotrapeziotrapezoid arthrodesis for isolated osteoarthritis: results at a mean 8 years' follow-up.

The aim of this retrospective study was to report medium- to long-term outcome of scaphotrapeziotrapezoid (STT) arthrodesis with staple fixation to treat painful isolated osteoarthritis (OA). Twenty-one consecutive patients (22 wrists) who had undergone STT arthrodesis were retrospectively reviewed by an independent examiner. Clinical and radiological evaluation was performed. At a mean follow-up of 8 years (range 2-20 years), pain levels were significantly decreased, and functional scores were significantly improved. Grip and pinch strength were 86% and 82% of those of the contralateral side. Wrist range of motion in flexion-extension and radial-ulnar deviation was significantly less than on the contralateral side at last follow-up (104° vs. 131° and 38° vs. 55°, respectively). Non-union was found on X-ray in 4 wrists (18%), but in 2 cases showed as partial non-union on CT, with complete scaphotrapezial consolidation; 1 of the 4 wrists required surgical revision. Another patient was re-operated on for symptomatic external staple displacement without non-union. There were 8 cases (36%) of radiographic narrowing of the styloscaphoid joint space; contact between the staple and styloid was found in all 8 cases. Four patients (18%) had narrowing of the scaphocapital joint space; protrusion of the proximal part of the staple into the joint space was noted in all 4 wrists. No differences were found for the radioscaphoid, capitolunate and scapholunate angles before and after surgery. STT arthrodesis with staple fixation to treat isolated STT OA led to a significant reduction in pain, with improved strength and functional scores. To avoid styloid impingement, we recommend systematic styloidectomy. Complete non-union seems to be overestimated on radiographs. Partial non-union with scaphotrapezial union should not be considered as a complication. LEVEL OF EVIDENCE: IV.

[Free temporoparietal flap in hand coverage. Report of three cases]. / Les transferts vascularisés de fascia temporalis dans les pertes de substance de la main. A propos de trois cas.

Hands defect coverage needs thin and pliable flaps. Few free flaps such as free temporoparietal flap are adequate. It provides moderate donor scar and unique range of motion for tendinous coverage. We expose three cases of hand reconstruction: two dorsal coverage with tendinous exposition and reconstruction and one thumb coverage. The postoperative results were satisfactory concerning hands. One patient developed alopecia and dysesthesis on scalp. We think that this flap is a good alternative for serratus free fascial flap.

Radioscapholunate fusion for posttraumatic osteoarthritis with consecutive excision of the distal scaphoid and the triquetrum: A comparative study.

The aim of this study was to assess the clinical and radiographic outcomes after radioscapholunate (RSL) fusion for posttraumatic osteoarthritis. This was a retrospective, dual-center study of all patients who underwent RSL fusion between 1995 and 2015 for posttraumatic radiocarpal osteoarthritis. Patients were assessed at the final review to determine clinical (pain, wrist range of motion and strength), self-reported (QuickDASH, PRWE and MWS scores) and radiological (degenerative osteoarthritis in the scaphotrapeziotrapezoid (STT) or midcarpal joint and radiocarpal fusion) outcomes. We analyzed three groups: RSL fusion alone, RSL fusion with distal scaphoid excision (DSE) and RSL fusion with DSE and triquetrum excision (TE). Eighty-five patients were included; 10 were lost to follow-up and 11 required conversion to total wrist fusion before the final review. Finally, 64 patients had both clinical and radiographic evaluations. The mean follow-up was 9.1 years (range 1-21.4). RSL fusion alone was performed in 29 patients, RSL fusion with DSE in 23 and RSL fusion with DSE and TE in 12. At the final follow-up, the three groups did not differ in their pain or wrist motion. Overall, 47 (73%) patients were satisfied or very satisfied with the procedure. DSE significantly decreased STT osteoarthritis and radiocarpal non-union. The total wrist osteoarthritis rate after RSL fusion was 55%. RSL fusion is an effective procedure to preserve some motion in wrists with posttraumatic radiocarpal osteoarthritis. DSE prevents STT osteoarthritis by removing bony impingement and increases the fusion rate. LEVEL OF EVIDENCE: Level IV, Case series, Therapeutic studies.

Distal interphalangeal joint arthrodesis using the X-Fuse® implant: A retrospective study of 54 fingers with 24 months' follow-up.

We report the clinical and radiographic results of distal interphalangeal (DIP) joint arthrodesis using the X-Fuse® implant with a mean follow-up of 24 months (6-54). Forty-one patients (33 women and 8 men) with a mean age of 65 years were operated on. DIP joint arthrodesis was performed on 54 fingers for advanced osteoarthritis resistant to medical treatment. Pain evaluated on a visual analog scale (/10) was reduced significantly, going from 5 to 0.47. Functional DASH and PRWE-Hand Scores (/100) were improved by 33 and 36 points, respectively. Four fingers (7.4%) were sensitive to cold. No cases of nail dystrophy were reported. The fusion rate was 89%. Of the six patients (11%) who suffered a non-union, there was one case of asymptomatic fracture of the implant, without reoperation, and one case of infection, which required revision surgery. The fusion position was stable at the review visit. The repeat surgery rate was 3.7%; both cases were for infection. In light of this study, the X-Fuse® implant is a viable alternative to traditional arthrodesis techniques (compression screws and pins), with a similar fusion rate. This implant appears to be very well tolerated by patients, with an absence of nail dystrophy and a reduction in the risk of infection.

Treatment of chronic scapholunate instability: Results with three-ligament tenodesis vs. scapholunate and intercarpal ligamentoplasty.

In this retrospective case control/comparison study, we compared the clinical and radiological outcomes in patients with chronic scapholunate dissociation treated with three-ligament tenodesis (3 LT) versus scapholunate and intercarpal ligamentoplasty (SLICL). Twenty patients with a mean age of 43 years were treated with the 3 LT procedure and 26 patients with a mean age of 44 years with the SLICL procedure. All patients had chronic reducible scapholunate dissociation without chondral lesions. The two groups of patients were operated on by senior surgeons, at the same facility, over two different time periods. All patients were evaluated (pain, motion, strength, function, X-rays) with a mean follow-up of 28 months (12-49) in the 3 LT group and 36 months (12-54) in the SLICL group. In the both groups, we found a significant improvement in pain levels, grip strength and functional scores (DASH and PRWE). The SLICL group had significantly less pain and greater grip strength than the 3 LT group. Patients in the SLICL group had a greater improvement in their DASH and PRWE Scores. The mean range of motion in flexion-extension was 82° (102° preoperative) in the 3 LT group and 113° (115° preoperative) in the SLICL group. In the 3 LT, there was no significant improvement in the mean static and dynamic scapholunate gaps (3.6 and 4.8 mm postoperatively versus 3.9 and 4.9 mm preoperatively), or the scapholunate angle (75° versus 72°). In the SLICL group, the mean static and dynamic gaps improved significantly (2.3 and 3.0 mm postoperatively versus 3.2 and 4.6 mm preoperatively), as did the scapholunate angle (62° versus 73°). In the 3 LT group, 4 patients developed osteoarthritis. In conclusion, the SLICL procedure for scapholunate ligament reconstruction led to better clinical and early radiological results than the 3 LT technique.

Pisiformectomy in advanced pisotriquetral joint arthritis: A retrospective study of 12 wrists with a mean follow-up of 7.5 years.

Pisiformectomy is the gold standard treatment for pisotriquetral arthritis resistant to conservative treatment. We evaluated the long-term clinical and functional outcomes after pisiformectomy in resistant pisotriquetral arthritis cases. We retrospectively evaluated 11 patients (12 wrists), mean age of 59 years (49-69) treated by pisiformectomy using a standardized surgical technique. Pisiformectomy was performed for primary osteoarthritis in 10 cases, for post-traumatic osteoarthritis in 1 case and for pisotriquetral instability in 1 case. The clinical and functional evaluation was carried out by an independent examiner. Mean time to review was 90 months (63-151). Pain on a Visual Analog Scale (/10) decreased significantly to 1.1 from 6.8 preoperatively. Mean range of motion was 79° in flexion, 61.5° in extension, 18° in ulnar deviation and 36° in radial deviation. Mean grip strength of the operated wrist was 86% of the non-operated wrist. Functional scores significantly improved with a gain of 40 points for the QuickDASH and 53 points for the PRWE. Based on this long-term follow-up study, pisiformectomy seems to alleviate wrist pain and improve the quality of life in a low-demand population with pisotriquetral osteoarthritis resistant to conservative treatment. When compared to the pisotriquetral arthrodesis, pisiformectomy is easier to perform, allows quicker mobilization of the wrist and leads to good functional outcomes.

Proximal interphalangeal joint arthroplasty with Tactys®: Clinical and radiographic results with a minimum follow-up of 12 months.

The Tactys® implant is a total anatomic gliding and modular prosthesis for proximal interphalangeal (PIP) arthritis. We report the clinical and radiographic results of this implant with a minimum follow-up of 12 months. Thirty-three implants in 27 patients with a mean age of 67 years were reviewed. Surgical approach was mid-line dorsal and trans-tendinous. Postoperative active motion was performed with a protective splint for 4 weeks. All patients were evaluated (pain, range of motion, strength, function through QuickDASH and PRWE scores, X-rays) by an independent examiner. The mean follow-up was 21 months (range: 12-30). Pain decreased from 7.4 to 1.6 on a VAS scale (P<0.001). Flexion-extension range of motion increased from 32.1° to 59.2° (P<0.001). Functional QuickDASH and PRWE improved from 64.5 and 67.1 to 25.5 and 19.5, respectively (P<0.001). Grip and pinch strength increased from 15.1 and 1.8 to 24.2 and 2.4kg/F, respectively (P<0.001). At the last follow-up, a swan neck deformity was noticed in three patients, which was reducible in all cases. Four patients were reoperated: dorsal tenoarthrolysis in three cases and correction of swan neck deformity in one case. On X-rays, asymptomatic periprosthetic ossifications were noticed in 13 cases (39%). There were no signs of implant migration or loosening. Our results are comparable to those of other published studies of PIP arthroplasty. The modularity of the Tactys® implant allows the range of motion of the PIP joint to be maintained. It is a reliable alternative to other conventional PIP implants. LEVEL OF EVIDENCE: Level 4, case series.

Epidemiology of traumatic upper limb amputations.

INTRODUCTION: While published data on functional outcomes after upper limb amputations are plentiful, epidemiology data are relatively rare. This led us to performing an epidemiology study of traumatic upper limb amputations at our facility. MATERIAL AND METHODS: This retrospective study spanned a 10-year period of cases seen at the SOS Main (Hand emergency center) of the Nancy University Hospital in France. Patients who suffered traumatic amputation of the upper limb were identified and divided into two groups: replantation and surgical amputation. All anatomical amputation levels were retained. Non-traumatic amputations were excluded. Epidemiology data (sex, age, dominant side, injured side) was collected along with the specific anatomical level of the injury, the injury mechanism and whether it was work-related. We also looked at the success rate of microsurgery and whether multi-finger amputations were partial or complete. In parallel, the annual incidence of amputations seen at the SOS Main over this period was calculated. RESULTS: Over the 10-year period, 1715 traumatic upper-limb amputations were identified, which was 3% of all cases seen at the SOS Main. Most of the cases involved middle-aged men. Revascularization was attempted in one-third of cases and microsurgery was successful in 70% of cases. The surgical amputation group consisted of 1132 patients with a mean age of 59 years, while the replantation group consisted of 583 patients with a mean age of 48 years. The primary mechanism of injury was a table saw. DISCUSSION: This injury, which must be addressed urgently, is not very common in everyday practice. This is contrary to lower limb amputations, which are more common and occur in the context of micro- and macroangiopathy in older patients. The success rate of microsurgery in this cohort must be placed in the context of age, amputation level and mechanism. The functional outcomes are not always as good as the vascular outcomes. This data is invaluable as it fills a gap in our knowledge about amputations. LEVEL OF EVIDENCE: IV.

Hypothenar hammer syndrome: A case of a late complication after surgery.

Hypothenar hammer syndrome is a rare condition secondary to ulnar artery damage in Guyon's canal, affecting mainly those exposed to repeated palm trauma. Surgery is discussed in cases of severe symptoms that are resistant to conservative treatment, and/or when anatomical lesions with high embolism potential are discovered during imaging exams. Resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after this type of surgical treatment was performed. There was an aneurysmal thrombosed vein graft with extensive thrombus from the ulnar artery upstream to Guyon's canal to the superficial palmar arch. Finger revascularization was provided by the superficial branch of the radial artery and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed to resect the thrombosed zone, including the vein graft, without vascular reconstruction due to the good vascularization of all the fingers, and to release the ulnar nerve at the wrist. The postoperative course was uneventful with the disappearance of pain and sensory-motor deficits. Good finger vascularization was confirmed by imaging at 3 months postoperative; nerve conduction was normal at 6 months on electroneuromyography.

[Hypothenar hammer syndrome: A recurrent case report after surgery]. / Syndrome du marteau hypothénarien : à propos d'un cas de récidive après traitement chirurgical.

Hypothenar hammer syndrome is a rare entity secondary to ulnar artery damage in the wrist, affecting mainly those exposed to repeated hand-palm trauma. Surgery is discussed in case of severe symptoms, resistant to medical treatment, and/or when anatomical lesions with emboligenic potential are demonstrated in the radiological exams. In this case, resection of the pathological zone with revascularization by autologous vein graft is the best option. We report the case of a 60-year-old patient who had a recurrence of symptoms more than 10 years after the completion of a surgical treatment. There was an aneurysmal thrombosed vein graft with extensive thrombus extending from the ulnar artery upstream of the Guyon's canal to the superficial palmar arch. The digital revascularization was provided by the radial superficial palmar arch and the presence of a collateral vascular supply. This late complication was responsible for compression of the ulnar nerve in Guyon's canal. A new surgery was performed consisting of the resection of the thrombosed zone, including the vein graft, without vascular reconstruction given the good vascularization of all the fingers, and release of the ulnar nerve to the wrist. The operative follow-up was uneventful with the disappearance of pain and sensory-motor deficits. Good digital vascularization was confirmed by imaging at 3 months postoperatively; nerve recovery by electromyogram at 6 months with normal conduction.

Treatment of chronic scapholunate dissociation with tenodesis: A systematic review.

Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature.

[The diagnosis of recent scaphoid fractures: review of the literature]. / Le diagnostic des fractures récentes du scaphoïde: revue de la littérature.

Fractures of the scaphoid are the most common carpal fractures. A review of the literature indicates that the prevalence of the fracture in the case of clinical suspicion is less than 50%. A quality X-ray examination remains essential as an initial diagnostic tool in the evaluation of scaphoid fractures. Its sensitivity varies from 59 to 79%. Patients with negative X-rays present with about 18.7% of scaphoid fractures; 5% of bruised scaphoid; 13% of radius fractures and 7% of miscellaneous bone lesions. If not treated promptly, a scaphoid fracture may be compounded by non-union with associated risk factors such as avascular necrosis and osteoarthritis. Considering these risks, patients with suspected scaphoid fracture with normal X-rays, routinely undergo wrist immobilization until imaging confirms or denies the presence of fracture. Consequently, more than half of the patients undergo wrist immobilization needlessly. This may have a negative impact on their professional life and personal activities while representing a high medical cost. MRI is the imaging technique of choice for suspicious or negatice X-rays. MDCT is less costly than MRI or bone scan, readily available and highly effective for trauma patients but is lacks accuracy and should be used with caution in this indication.

Complete section of proper palmar digital pedicles: Correlation between arterial patency and sensory recovery.

Wounds to proper palmar digital (PPD) pedicles are frequent surgical emergencies. A correlation between arterial patency and nerve regeneration, however, has never been demonstrated. Forty-seven patients presenting complete section of a PPD pedicle and having undergone surgical repair of both elements were followed-up at a minimum of one year postoperatively. Doppler ultrasound examination studied arterial patency as well as the degree of stenosis. Neurological examination determined the BMRC score and the existence of cold intolerance, symptomatic neuroma and neurogenic pain. In 32 cases, the artery was permeable; in the remaining 15, arterial thrombosis was identified. In 14 out of the 32 permeable-artery subjects, stenosis had no significant effect; in the remaining 18 cases, circulation was reduced. BMRC scores showed 11 S4 cases, 16 S3+, 16 S3 and 4 S2. Twenty-nine cases of intolerance to cold were identified, along with two cases of neurogenic pain and 17 cases of symptomatic neuroma. A statistically significant correlation was shown between arterial patency and BMRC scores (Chi-square, P=0.0221) and neurological symptoms appeared to be linked to the degree of stenosis. Favorable BMRC scores were observed where the artery was permeable, notably where blood flow was not modified below the repair site. This observation also seemed valid regarding disabling neurogenic symptoms.

Lipofibromatous hamartoma of the radial nerve: An unusual location.

Lipofibromatous hamartoma is a congenital and ineradicable benign tumour of the peripheral nerve sheaths, affecting almost exclusively the median nerve and its branches. It corresponds to an infiltration of the nerve by lipofibramatous tissue that dissociates the fascicles. We report a highly unusual case of a lipofibromatous hamartoma of the radial nerve in the upper extremity in a 52-year-old female patient.