["Principalisation" of pollicization in congenital conditions. Technical modifications for functional and aesthetic improvement]. / Cahier des charges en vue d'améliorer l'aspect esthétique et fonctionnel de la pollicisation dans les différences congénitales. Propositions techniques.

After reviewing our experience of pollicization in congenital differences, we found that classical techniques have several weak points concerning function and appearance. Abduction is frequently insufficient and adduction quite weak. Aesthetically, the thumb has a slender aspect and the web fold is absent and the commissure looks more as a cleft. We tried to " principalize" the issues to propose some technical modifications for improvement of function and appearance.

[Flexion deformities of the thumb: clasped thumb and trigger thumb]. / Déformation en flexion du pouce de l'enfant: pouce flexus adductus et pouce à ressaut.

Congenital clasped thumb in palm corresponds to a spectrum of anomalies leading to a loss of thumb extension and abduction. Intrinsic muscles and skin shortening are not infrequent. Conservative orthopedic treatment should be undergone as soon as possible. When this treatment fails, or when patients are seen late, surgical correction has to be customized according to the involved structures. The trigger thumb is 10 times more frequent than the trigger finger. It is bilateral in 30% of the cases. The term "congenital" remains unclear as several investigations on newborns have not evidenced trigger thumb. In children, it is very rare to find a real trigger and presentation consists in a fixed flexion deformity of the interphalangeal joint. Diagnosis is clinical, with a palpable nodule at the level of T1 pulley. Conservative treatment, consisting in a nocturnal splint, is indicated before the age of two years old. After this age, or in case of failure of splinting, surgery will be needed.

[Early physiolysis in the correction of clinodactyly]. / La physiolyse précoce dans la correction de la clinodactylie.

The principle of early treatment by physiolysis without osteotomy is based on the removal of the deforming tether. We retrospectively studied the effects of early physiolysis on the growth and correction of deformity with a minimal follow-up of 6 years in 17 cases. The mean correction at follow-up was 82% of the pre-operative angle. All operated phalanges had grown. There was no epiphyseal closure. Full correction (residual deformity of less than 10 degrees) was achieved in 11 patients. No patients needed closing osteotomy for insufficient correction. We think that early physiolysis is a quick operation which provides growth and at least partial correction of the clinodactyly.

Conservative treatment versus scaphotrapeziotrapezoid arthrodesis for Kienbock's disease. A retrospective study.

Efficiency of surgical treatment in Kienböck's disease has never been proven in the long term. We retrospectively reviewed the charts of the 104 patients treated by various techniques for Kienböck's disease from 1981 to 1999 in our unit. A comparison was made between 19 cases treated conservatively (amongst 59) and 11 cases (amongst 25) treated by scaphotrapeziotrapezoid (STT) arthrodesis with a mean follow-up of 13 years. The two groups were statistically comparable in stage, age, sex ratio, number of manual workers. STT arthrodesis was responsible for an increased loss of mobility, an increase of barometric pain, a longer rehabilitation time and more fractures of lunatum than conservative treatment. Those results question about indications for STT in Kienböck's disease.

[Thumb reconstruction in emergency, not including replantation]. / La reconstruction en urgence du pouce, à l'exception de la replantation.

Many articles have discussed secondary thumb reconstruction but only few have been devoted to acute reconstruction. We propose to artificially separate four circumstances: (i) the thumb is preservable without associated trauma of the fingers. The rule is not to burn the bridge of secondary reconstruction; (ii) the thumb is preservable but a neighboring finger is seriously injured and functionally condemned. The finger has to be used as a "bank" to borrow the necessary anatomical structures for reconstruction of the thumb; (iii) the thumb is not preservable and the lesions of a neighboring finger allow to use it for a pollicization. The difficult decision is between the immediate transposition or maintenance for secondary pollicization. Only finger devascularization is a clear indication for acute pollicization; (iv) Finally when the thumb is not preservable and there is no associate finger injury, it is difficult to assess and inform sufficiently the patient to take a decision. Secondary thumb reconstruction is the best choice.

Debilitating chronic pain syndromes after presumed intraneural injections.

This report presents seven patients with severe disability established at the time of a peripheral nerve block. In most of the cases, the injection was administered as a routine procedure by an experienced anesthesiologist. The patient histories suggest that the condition, which can be resistant to all treatment, in most cases could have been avoided if careful attention had been given to the occurrence of pain during the nerve block. It is likely that the risk of devastating iatrogenic disability can be minimized if a few basic principles are respected during the administration of peripheral nerve blocks.

Three-phase bone scanning in reflex sympathetic dystrophy of the hand.

Three-phase bone scanning was performed in 181 patients suffering from reflex sympathetic dystrophy (RSD) of the hand. Four quantitative parameters were defined as follows: (a) hemovelocity and (b) blood pool (determined from the Fourier processing of angiographic data); (c) early (3-5 min) and (d) delayed (2-3 hr) bone fixation. Three significant stages of RSD were demonstrated scintigraphically. Stage I (0-20 wk from onset) demonstrated increases in velocity, blood pool, and early and delayed fixations. At stage II (20-60 wk) blood velocity and blood pool were normalized, but early and delayed hyperfixation persisted. During stage III (60-100 wk) blood velocity and blood pool were reduced on the affected hand, and early and delayed fixations were normalized. Such abnormality of decreased hemodynamic parameters may become associated with bone hypofixation in stage III. Early treatment of RSD (as compared with delayed treatment) has been demonstrated to induce normalization of hemovelocity (p less than 0.05), blood pool (p less than 0.02), and joint stiffness (p less than 0.001) without any change in the bone fixation; therefore, three-phase bone scanning may provide useful information regarding the pathophysiologic and clinical evolution of RSD.

Transfer of a severely damaged digit to reconstruct an amputated thumb.

We retrospectively reviewed the results of reconstruction of a traumatically amputated thumb with use of an adjacent severely damaged digit in twenty-seven patients (twenty-five male and two female patients). The mean duration of follow-up was nine years (range, two to twenty-one years). The mean age at the time of the reconstruction was thirty-four years (range, thirteen to fifty-six years). Five patients had the reconstruction on the day of the injury and twenty-two, after a mean delay of five months (range, fifteen days to thirteen months). Segments of the index finger were used in twenty-two patients; of the long finger, in four patients; and of the ring finger, in one patient. There were four complications: necrosis of the dorsal skin in one patient, reflex sympathetic dystrophy in one patient, and contracture of the first web space in two patients. Discriminative sensibility was ten millimeters or less, according to the Weber test, in twenty-four thumbs. Cortical integration with reference to the recipient thumb, on stimulation of the pollicized segment, was good in ten patients. Eleven patients could achieve tip-to-tip contact between the thumb and the little finger and twenty-five patients, between the thumb and the most radial finger. The ability to perform activities of daily living was considered good for ten patients, fair for eleven, and poor for six. Only digits with a nail, either present on the transferred segment or as a result of a free vascularized nail transfer, were considered to have a good cosmetic result. Although these results are far from impressive, the reconstruction is a viable alternative for selected patients because it maintains the ability to grasp objects and to oppose the digits.

Detection of glomus tumor of the finger by dedicated MRI at 0.1 T.

Three glomus tumors of the fingers were detected using a dedicated hand and wrist low field (0.1 T) MR imager equipped with solenoidal coils allowing a FOV of 2 cm. Three-dimensional T1-, T*2-, or T2-weighted images were used (8 contiguous slices of 2 mm thickness). Glomus tumors had low or intermediate signal intensity (2 cases) or no signal (1 case) on T1-weighted images. On T*2- or T2-weighted images they had high signal intensity. MRI findings correlate well with surgery and biopsy.

Digital reconstruction with island flaps.

Better understanding of the vascular anatomy of the hand and of flap perfusion allows the hand surgeon to perform single-stage reconstruction of digital defects through a multitude of island flap transfers. The usefulness of more than 20 separate island flaps is discussed, and the technique of flap transfer is presented for each.

The bipolar lengthening technique: a modified partial toe transfer for thumb reconstruction.

The authors describe a new technique for reconstruction of the thumb after amputation through the proximal phalanx. Bipolar lengthening is a combination of first web deepening by an Ostrowski flap and a distal lengthening by a free vascularized compound transfer of pulp, nail, and bone harvested longitudinally from the distal phalanx of the great toe. Seven cases have been reviewed by an independent observer after a mean follow-up of 46 months. There were no technical failures. The mean static 2-point discrimination was 6.3 mm, and the Semmes-Weinstein monofilament testing was identical to that of the contralateral side in four patients and increased in the other three. After correction for hand dominance, grip strength was 89 percent of that of the contralateral side, and pinch strength was 81 percent of that of the contralateral side. First web span was symmetric in four patients and diminished in the other three. The bipolar technique creates a short thumb, which avoids exposing the thumb to trauma when making a fist, without limiting first web span.

Association of Wartenberg's syndrome and De Quervain's disease: a series of 26 cases.

We report on a series of 25 patients (26 cases) presenting an association of Wartenberg's radial neuritis and De Quervain's tenosynovitis. In all patients the diagnosis was made on clinical grounds. In group 1, conservative treatment of Wartenberg's syndrome was used in 16 patients (associated with surgical release of the first extensor compartment in 5 patients). Of the 14 patients available for follow-up at an average of 15 months, 9 (64 percent) were excellent and good results. In group 2 (11 patients, with 1 failure of conservative treatment), surgical treatment addressed both conditions. Neurolysis has to be performed at the classic proximal site of entrapment (constant excellent and good results), for the 2 cases of neurolysis at the styloid level gave fair results. It is particularly important to identify an associated Wartenberg's syndrome before performing a release of the first dorsal compartment to avoid incomplete relief or even aggravation of neuritis, exposing the surgeon to litigation.

A new island flap transfer from the dorsum of the index to the thumb.

We describe here a new island flap from the dorsum of the index finger, transferred on the first dorsal metacarpal artery with one or two veins and the terminal branches of the radial nerve. This vascular bundle is a reliable one, for we have had no necrosis in 12 consecutive cases. The quality of its venous outflow and the use of a dorsal donor site give it advantages over the Moberg-Littler island flap, unless a dorsal vein from the latter flap is preserved and sutured to a vein in the recipient site. The arterial vascularization without any skin pedicle makes this "kite" flap a more practical one than the "flag" flaps of Vilain or Holevitch or Kuhn. Finally, a one-stage transfer is usually preferable to a two-stage one (e.g. Adamson, Braillar). In a single operation, this transfer provides composite resurfacing of the thumb while bringing in new blood and nerve supply.

Custom-made free vascularized compound toe transfer for traumatic dorsal loss of the thumb.

Dorsal compound traumatic thumb loss can be reconstructed in selected young and well-motivated patients with a custom-made partial great toe transfer. The transfer, including the nail complex and vascularized piece of bone, can be fashioned by longitudinally cutting the distal phalanx to approach the appearance of the opposite thumb and to allow for more normal nail appearance. Ten patients illustrate this technique and emphasize its reconstructive potential as well as cosmetic acceptance.

Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases.

The foot is an invaluable bank of spare parts available for reconstructing the mutilated hand. The dorsalis pedis flap, the extensor digitorum brevis muscle, and the first and second toes can now be used as free transfers. We believe that partial toe transfers, including either sensitive cutaneous flaps or composite tissue, are also extremely useful in properly selected patients.

Metacarpal synostosis: a simple classification and a new treatment technique.

The current classification of metacarpal synostosis is based on the extent of the synostosis. The authors propose a new classification that takes into account the shape of the metacarpal bones, the curvature of the epiphysis, and the discrepancy in length between the two bones. This classification provides better guidelines for the correction of all components of the deformity. The classification is based on the authors' observations of and experience with 36 cases of metacarpal synostosis; 13 of the deformities were surgically corrected. The I-shaped deformity, whether with distinct (type d) or fused (type f) metacarpophalangeal joints, does not require surgical correction. The U-shaped deformity has parallel epiphysis and does not require surgery unless the two metacarpals are asymmetrical in length (type a) or tightly fused (type t); in these cases, simple lengthening or widening of the space with a bone graft is sufficient. Y-shaped synostosis should be separated whether the branches are symmetrical or asymmetrical, the latter having one branch shorter than the other. Because the epiphyses are already divergent, simple separation does not effectively correct Y-shaped synostosis. The authors propose an osteotomy to isolate a trapezoidal segment of bone from the bifurcation. The isolated bone segment is then reversed in the proximal-distal direction to provide a "plateau" upon which the two distal metacarpals can be realigned. Two cases of Ys (symmetrical) synostosis were successfully treated with this technique; one case of Ya (asymmetrical) synostosis also required distraction lengthening of the shorter metacarpal to achieve an excellent result. One of the most difficult types of metacarpal synostosis to treat is k-shaped synostosis, observed only between the fourth and fifth metacarpals; in this type, the head of the short fifth metacarpal abuts the metaphysis of the fourth. Osteotomy and distraction lengthening provide predictable results for correction of this deformity. The authors suggest that k-shaped synostosis might represent a late evolution of untreated Ua synostosis.

Correction of first web space deficiency in congenital deformities of the hand with the pseudokite flap.

The authors describe a new flap to enlarge or create a first web in patients with congenital deficiencies of the hand. This lozenge-shaped flap is harvested from the dorsoradial aspect of the index finger based on a narrow proximal skin bridge protecting its axial vascularization. A dorsal skin graft of the donor site is avoided by closure using a rhomboid flap. Procedures in 16 patients were performed and reviewed; the only complication was insertion of a small split-thickness graft in five patients to avoid tension at the metacarpophalangeal joint level. The flap lengthened the web fold an average of 3.2 cm without "pseudolengthening" the thumb.

Thumb reconstruction by micro-vascular techniques.

Sixty-three patients with thumb reconstruction by total or partial toe transfer have been reviewed. Mean age was 25 years. Males (84%) and manual workers (76%) dominated the series. The rate of failure was 3%. Second toe transfer gave a functionally acceptable thumb with 10 mm two point discrimination, 59% of strength in pinching (compared to normal side), 30 degrees of range of flexion but with a flessum deformity (average 27 degrees) and a poor cosmesis score (1.5 on a 5 point scale). Partial toe transfers were useful in amputations at metacarpophalangeal (MP) level and distal to this area. Around MP level, three techniques were available: wrap around, Twisted Two Toes and "bipolar" lengthening. More distally a "custom made" transfer allows to match exactly the defect. All of these techniques save the great toe length. When a pulp was incorporated in the transfer, two point discrimination averaged 9 mm and in the entire series the mean pinch strength was 93% normal and the mean cosmetic score was 3.5 points. Partial toe transfers are preferable in cases with any otherwise normal hand, providing good function and better cosmesis.

A comparison of different surgical techniques in treating degenerative arthrosis of the carpometacarpal joint of the thumb. A retrospective study of 98 cases.

Between March 1977 and December 1991, 98 surgical procedures on 85 patients were performed at SOS Main Strasbourg for osteoarthrosis of the carpometacarpal joint of the thumb. The mean age was 56 and 90% were female; 13 were operated on bilaterally. 40% had Swanson arthroplasties (group 1), 15% Ashworth-Blatt hemiarthroplasties (group 2), and 45% had soft tissue arthroplasties (group 3). 62 cases were reviewed at an average follow-up of 5 years. Normal thumb range of motion was obtained in all cases, regardless of the technique used. Complete pain relief was achieved in 77% of the cases in group 1, 37.5% in group 2 and 71% in group 3. 15% of group 1 and 50% of group 2 required surgical revision, either for displacement or fracture of the implants. No revision was necessary in group 3. One case of silicone synovitis requiring secondary surgery was noted 6 years after surgery, accounting for 2.9% of the total number of silicone implants reviewed, but radiological signs of silicone synovitis were much more common (56%). Proximal metacarpal migration in group 3 averaged 38% of the initial arthroplasty space, and was not related to the type of ligamentoplasty used, or presence or absence of an "anchovy". The migration increased to 68% of the space if an associated MP joint arthrodesis was carried out at the same time. Complications included reflex sympathetic dystrophy (4% in group 1 and 14% in group 3). The Ashworth-Blatt hemiarthroplasty failed to gain satisfactory results, but both silicone arthroplasty and soft tissue arthroplasty proved to be useful procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Pinch reconstruction by hand to hand finger transfer associated with hallux transfer after a severe frostbite injury.

We report a case of severe frostbite in which a pincer hand was created by microsurgical transfer of a partially amputated small finger from the opposite hand combined with microsurgical transfer of a partially amputated great toe which was subsequently lengthened.