Ultrasound-guided transection of the interosseous membrane of the forearm.

We sought to evaluate the feasibility of ultrasound-guided transection of the interosseous membrane of the forearm. The study involved ten forearms from five fresh cadavers. An ultrasound scanner (Toshiba™ Aplio V®, Toshigi, Japan) with a linear probe (Toshiba™ PLT-805AT 8Mhz) and a 25-cm long Kemis® knife (NewClip Technics™, Cholet, France), which was specially created for this study, were used. An approach to the distal and proximal radioulnar joint was made before the transection. The induced muscle hernia sign and the radius joystick test were performed to confirm the effectiveness of the ultrasound-guided transection. Complete dissection of the posterior surface of the forearm was done to check for complications and evaluate the quality of the transection. We registered nine complete transections of the interosseous membrane. The muscular hernia sign was present in all the cases performed. The joystick test was positive in eight cases. One forearm had a vascular complication. This ultrasound-guided interosseous membrane transection technique is feasible and effective with limited vascular and nerve risks. A prospective clinical study is required to validate this anatomical work.

Surgical ultrasound-guided carpal tunnel release.

Ultrasound-guided surgery is a new trend stemming from the introduction of high-frequency linear probes and better quality screens. Surgical treatment of carpal tunnel syndrome is increasingly being performed under ultrasound guidance. Knowledge of musculoskeletal ultrasonography is obviously mandatory. Several types of cutting instruments (miniature knife, Gigli saw or hook) and surgical approaches (wrist or palm) have been described. Ultrasonography allows the wide-awake and local anesthesia with no tourniquet (WALANT) technique to be used in the context of ambulatory patient care. The practitioner must be aware of all the possible intraoperative and postoperative complications, and be able to treat them. The aim of this review is to analyze the literature on the feasibility and outcomes of surgical ultrasound-guided carpal tunnel release, and to compare it to the other validated techniques.

Wide-awake ultrasound-guided percutaneous extensor central slip tenotomy for chronic mallet finger: A prospective study of 14 cases (with videos).

The central slip tenotomy described by Fowler is an effective option for treating chronic mallet finger in order to avoid swan neck deformity of the finger. In a prospective study of 14 cases (13 failures of conservative treatment and one case of untreated mallet finger), we performed percutaneous ultrasound-guided central slip tenotomy with a 19 G needle using the wide-awake local anesthesia and no tourniquet (WALANT) technique. The mean extensor lag before surgery was 28° (range 20°-40°) and three patients had a swan neck deformity. The anesthesia and tenotomy were guided with a 15MHz high frequency probe. Patient were asked to grade their pain between 0 (no pain) and 10 (extreme pain) with a Visual Analog Scale (VAS), to flex and extend their finger immediately after the tenotomy and to be reviewed at 1month's follow-up. The mean pain score on VAS during the procedure was 1/10 (range 0-3). After several movements of the finger after the procedure, two patients immediately regained full extension of the distal interphalangeal joint. At 1month follow-up, the correction was complete for 10 patients, three patients had a residual deformity of 10° and one had a poor result with a 30° deformity. Two patients had a persistent painless synovitis of the proximal interphalangeal joint. Thirteen patients were fully satisfied and one was a disappointed, but did not want another treatment. There are no published reports of percutaneous central slip tenotomy. In this preliminary report, central slip tenotomy for chronic mallet finger with ultrasonography was painless, effective and safe under WALANT technique. Larger clinical studies are needed to confirm the outcomes of this study.

Continuous in situ diffusion of ropivacaine for ambulatory congenital hand disorders surgery in young children.

Pediatric ambulatory surgery presents a specific set of challenges to the anesthesiologist. Similarly to adult ambulatory surgery, we report four ambulatory surgical procedures in two young children with congenital hand disorders. For each surgical procedure pain was controlled with continuous in situ infusion of ropivacaine.

[Continuous infusion of ropivacaine has no effects on pyrolytic implant: a preliminary study in rats]. / La diffusion continue de ropivacaïne in situ n'a pas d'effet sur le pyrocarbone : une étude in vivo chez le rat.

The aim of the study is to analyse the effects of ropivacaïne on a pyrolytic implant in bone surgery. Ten rats were operated with a pyrolytic implant placed at the hip after femoral head resection: five cases with continuous infusion of ropivacaïne and five cases with continuous infusion of sterile water. Six days after, all the implants were analysed: weight, length, width, thickness and global design. This work showed that ropivacaïne can be use as continuous infusion with pyrolytic implant. Other studies in human surgery are necessary.

[Spontaneous rupture of extensor pollicis longus in isolated trapeziometacarpal arthritis]. / Rupture spontanée du long extenseur du pouce sur arthrose trapézométacarpienne : à propos d'un cas et revue de la littérature.

A spontaneous rupture of the extensor pollicis longus (EPL) tendon occurred in a patient with trapeziometacarpal arthritis. We hypothesize that a mechanical attrition by protrusion at the trapeziometacarpal joint alone was responsible of a spontaneous rupture of the extensor pollicis longus tendon.

[Malingue's procedure for digital retraction in Dupuytren's contracture--principle, modelling and clinical evaluation]. / La plastie de Malingue dans les rétractions digitales de la maladie de Dupuytren: principe, modélisation et application clinique.

INTRODUCTION: Malingue's procedure is a modified Z-plasty for the treatment of digital retraction in Dupuytren's contracture. Geometrical modelling was used to determine the theoretical efficacy of the technique, and the clinical value of the method was assessed with a follow-up of 23 patients over at least two years. MATERIAL AND METHODS: Unlike Z-plasty, in which the skin flaps transposed are triangular, the Malingue plasty uses trapezoidal flaps. The direct longitudinal approach is used for the cords and the incision lines cut obliquely across the flexion folds. Euclidean geometry allows calculation of the average theoretical gain with a 45 plasty for a finger of width a, the initial surface being given by S1=a²âˆš2, and the surface after plasty by S2=a²(3/4×[√2+1]). A continuous, homogeneous, retrospective series of 27 patients operated by the same surgeon for Dupuytren's contracture with digital flexion contracture was reviewed by a neutral observer. The technique, which combined open-palm fasciectomy with the Malingue plasty, reduced the loss of skin by extending the finger after excising the cords. The plasty was adapted to cover various skin conditions and degrees of finger flexion contracture. RESULTS: The Malingue procedure was performed as an outpatient procedure in 23 cases. The average theoretical gain of the skin surface was 46%. The results were evaluated immediately after surgery and over a mean follow-up of 31 months. There were ten cases for a first operation, ten with a first recurrence, and seven with a second recurrence. The operated fingers healed within three weeks with no skin distress or dehiscence. The only surgical complication involved a sectioned collateral radial nerve of the ring finger in a recurrence of Dupuytren's contracture; a venous sleeve was used to re-establish the continuity of the nerve. Midterm complications included CRPS in one patient, recurrence of contracture in three patients, and benign lateral hypoesthesia of the first phalanx in two patients. The mean Tubiana score, which fell from 4.0 to 0.18 immediately after surgery, was 0.67 at the last follow-up, with an overall patient satisfaction index of 95%. CONCLUSION: The Malingue plasty follows a strict but easily applicable protocol. Avoiding the use of skin grafts or flaps, the technique offers satisfactory treatment in most cases of Dupuytren's contracture.

[Should we reconstruct the flexor retinaculum in the carpal tunnel?]. / Faut-il reconstruire le rétinaculum des fléchisseurs (retinaculum flexorum) dans le canal carpien?

Conflicting data in the literature justify this review about the flexor retinaculum (FR). Reconstruction of the FR following carpal tunnel open release has been recommended in order to limit the drawbacks of open carpal tunnel release; these drawbacks have been reported in wide series of results published between 1956 and 1988. This paper includes a review of the literature, a survey of the practice of the members of the French society for surgery of the hand (GEM), a self-evaluation of grip strength as well as a summary of indications.

Isolated interfragmentary compression for nonunion of humeral shaft fractures initially treated by nailing: A preliminary report of seven cases.

INTRODUCTION: Plating with bone grafting is considered the gold standard treatment for nonunion of humeral shaft fractures. However, this complex procedure involves multiple risks. The aim of this study is to evaluate an alternative treatment using isolated axial interfragmentary compression for the dynamisation of humeral shaft nonunion after retrograde locked nailing. MATERIALS AND METHODS: Between January 2000 and May 2009, 124 humeral shaft fractures were treated in our trauma department with retrograde locked nailing using the unreamed humeral nail (UHN(®), Synthes, Paoli, PA, USA). Nonunion occurred in seven patients (5.6%) - five females and two males, mean age 44 years (range: 17-73 years). The nonunion was treated by applying isolated secondary interfragmentary compression. Mean follow-up was 43 months (range: 8-74 months). The Rommens score and the disabilities of the arm, shoulder and hand (DASH) score were used to evaluate the global functioning of the upper limb. RESULTS: The compression procedure was successful in all seven cases. In each case, the union occurred without any complications in 3-5 months. The mean DASH score was 25/100 (range: 8.3-60.8/100). The Rommens score was judged excellent for five of the seven patients but two were rated moderate. One of these suffered from complex regional pain syndrome type II since the fracture, and another developed a stiff shoulder 6 months after trauma. CONCLUSION: Isolated secondary interfragmentary compression appears to be a simple and successful procedure in cases of humeral nonunion.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Congenital scaphotrapezial synostosis associated with a carpal tunnel syndrome: a case report]. / Synostose scaphotrapézienne associée à un syndrome du canal carpien chez une enfant de neuf ans : à propos d'un cas.

This report describes a case of congenital synostosis between two bones of the wrist scaphoid and trapezium in a nine-year-old girl who presented a severe tunnel carpal syndrome treated two years ago by open surgery. This association has not previously been described.

[Comminuted intra-articular fractures of the distal humerus in elderly patients]. / Fractures articulaires complexes de l'extrémité distale de l'humérus chez le sujet âgé

Treatment of comminuted intra-articular fractures of the distal humerus in elderly patients remains a challenge in trauma surgery. These fractures are rare, but their frequency increases. Our multicenter studies collected 238 cases of comminuted intra-articular fractures of the distal humerus in patients older than 65: two hundred and five cases for the retrospective study, 33 for the prospective study with a minimum follow-up of six months. The following criterias were studied: age, sex, state of health (with ASA score), functional scores (with Katz score), osteoporosis by the OST score and dual X-ray absorptiometry. The results were evaluated according to the Mayo Elbow Performance Score (Morrey) and the Quick DASH. X-ray studies were performed in order to assess both results for prosthesis and osteosynthesis. The following criteria were studied: bone healing, quality of reduction, signs of arthritis (Broberg-Morrey), prosthetic position, mechanical complications, prosthesis fixation. There were 80% of women in good health according to the ASA score (more than 70% of ASA 1 or 2). Most of them (80%) were self-governing and living at home. Hundred and seventy-two patients had an osteosynthesis and 44 had a prosthetic reconstruction (like Coonrad-Morrey prosthesis). Patients treated with osteosynthesis were younger (mean age was 77) than those treated with prosthetic reconstruction (mean age 81). Mean follow-up was 32 months. Results of osteosynthesis were good and excellent for 77% of the patients. Complications occurred for 20% of patients with a reoperation rate of 13%. Results of prosthetic reconstruction were good and excellent for 83% of the patients with 14% of complications and 6% of reoperation. Prosthetic reconstruction seemed to be better than osteosynthesis according to the Mayo Clinic score (84 points versus 77 points for the retrospective study and 95 points versus 75 points for the prospective study). However, the statistical analysis was not significant. Treatment of these fractures must be discussed according to the physiological status of the patient and the fracture patterns (scan evaluation). In conclusion, osteosynthesis remains the standard treatment when stable fixation is feasible. However, prosthetic reconstruction should be discussed for dependant patients or with comorbidity factors, bad bone quality leading to poor osteosynthesis or complex fracture.

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

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

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

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

[Retrograde locked nailing of humeral shaft fractures: a prospective study of 58 cases]. / Traitement des fractures récentes de la diaphyse humérale par enclouage centromédullaire verrouillé rétrograde: une étude prospective de 58 cas.

PURPOSE OF THE STUDY: Appropriate treatment for humeral shaft fractures remains a debated issue. Among the classical osteosynthesis techniques proposed, closed nailing was adapted to the humerus rather late, using the anterograde method. Use of retrograde nailing, which spares the rotator cuff, is more recent. The purpose of this study was to report outcome in 58 humeral shaft fractures in adults treated using the universal humeral nail between January 2000 and December 2003. MATERIAL AND METHODS: This work was limited to recent shaft fractures in adults with non-pathological bones. The fractures included were all situated between the insertion of the pectoralis major and a point situated 2 cm above the apex of the olecraneum fossa. The series included 58 patients with 58 humeral shaft fractures. All fractures were closed except four (Gustilo type I and II). Two patients presented preoperative radial paralysis which was not considered to be a contraindication for retrograde locking nailing. The paralysis recovered in both patients, after neurolysis performed during the nailing procedure in one. Osteosynthesis was performed without opening the fracture focus under fluoroscopic control using a static locking nail inserted retrograde in patients in the supine position. RESULTS: There were two early deaths unrelated to the method. Healing was obtained in the surviving patients within fifteen weeks on average. Bone healing was primary in 53 patients and after secondary compression in three. At last follow-up, shoulder motion was normal in 88% of patients and elbow motion in 91%. The Rommens functional score was good in 84%. Complications included three cases of spontaneously regressive postoperative radial paralysis, three cases of reflex dystrophy including two which regressed, and two cases of humeral palette fracture requiring surgical osteosynthesis. The proximal screws were removed in six patients because of pain or migration. To date, implants have been removed in three patients without problem. There were no infections. CONCLUSION: Retrograde insertion of this nail facilitates treatment of humeral shaft fractures by allowing immediate joint motion and the advantages of closed reduction: no infection, no late bone healing requiring conversion to another method of fixation. The residual technical problems concern proximal nailing and nail introduction.

[Spontaneous rupture of extensor pollicis longus in systemic lupus erythematosus]. / Rupture spontanée du long extenseur du pouce dans le cadre du lupus érythémateux disséminé. Cas clinique et revue de la littérature.

We report a case of spontaneous rupture of extensor pollicis longus of the left hand. This 63 year-old woman was treated with oral corticosteroids for 23 years because of systemic lupus erythematosus. Her hands had no deformity. This rupture was spontaneous and caused pain for 15 days. The treatment was surgical and consisted of an extensor indicis proprius transposition. There was no macroscopic tenosynovitis. The follow-up of one year showed a good result. Less than 40 spontaneous ruptures in systemic lupus erythematosus have been described in the literature; only seven cases were ruptures of hand tendons and only extensors. As far as we know, the spontaneous rupture of extensor pollicis longus has never been described in systemic lupus erythematosus. The role of corticosteroids is discussed.