[Coverage of a hand palmar defect by a synovial flap of the flexor digitorum superficialis]. / Couverture d'une perte de substance palmaire par un lambeau synovial des fléchisseurs superficiels des doigts.

Post-traumatic palmar soft tissue defects are a difficult problem in plastic surgery and many techniques have been described. We report the case of a 41-year-old patient with a large palmar soft tissue defect of the right hand due to a work accident. The classical flaps used in this indication were not usable. So, we chose the synovial flap of the Flexor digitorum superficialis to cover this palmar defect. We discuss the coverage possibilities for a hand palmar defect in emergency, and the use of the synovial flap in this indication. This case report shows that the synovial flap could be an option for the coverage of palmar soft tissue defects.

Anterior knee laxity measurement: comparison of passive stress radiographs Telos(®) and "Lerat", and GNRB(®) arthrometer.

INTRODUCTION: In patients with anterior cruciate ligament (ACL) tears, anterior laxity can be measured using stress radiographs or more recently introduced electronic measurement devices. HYPOTHESIS: The GNRB(®) arthrometer offers a radiation-free method of measuring anterior knee laxity whose diagnostic value is identical to that of Telos(®) or Lerat stress radiographs. PATIENTS AND METHODS: One hundred and fifty-seven patients (40 years [18-69]) scheduled for knee arthroscopy were evaluated using the GNRB(®) and two series of stress radiographs of both knees, one obtained using a 250-N Telos(®) device and the other using the technique described by Lerat (posterior translation of the femur/tibia under a 9-kg loading device). Arthroscopic evaluation of the ACL served as the reference standard for assessing the diagnostic performance of the radiological and instrumental laxity measurements. RESULTS: Under arthroscopic examination, the ACL was normal in 50.3%; "healed to roof of the notch" (partial tear) in 9.6%, "posterolateral bundle preserved" (partial tear) in 7.0%, "healed to the posterior cruciate ligament" (PCL) in 17.8%, and "empty notch" (complete tear) in 15.3%. In partial ACL tears, no significant differences in anterior laxity were found across the three measurement techniques. Telos(®) and GNRB(®) laxities were greater in the complete-tear group than in the normal-ACL, partial-tear, and healed-to-PCL groups. With the Lerat technique, the only significant differences were between the complete-tear group and the normal-ACL and partial-tear groups. Telos(®) and GNRB(®) showed similar diagnostic performance (sensitivity>62%, specificity>75%), whereas the Lerat technique lacked sensitivity (sensitivity=43.2%, specificity=82.7%) at 3mm. DISCUSSION: Diagnostic performance was lower in our study than in earlier reports. The GNRB(®) performed as well as Telos(®). The non-irradiating nature of GNRB(®) assessments allows repeated measurements for therapeutic or diagnostic purposes. LEVEL OF EVIDENCE: Level III, prospective case-control study.

Risks relating to posterior 2-portal arthroscopic subtalar arthrodesis and articular surfaces abrasion quality achievable with these approaches: a cadaver study.

INTRODUCTION: Many techniques for arthroscopic subtalar arthrodesis have been described since 1985. The procedure can be challenging because posterior and anterior portals are used conjointly with distraction. A posterior 2-portal approach was described in 2000. HYPOTHESIS: The goal of this study was to evaluate the quality of the freshening that can be achieved in the posterior subtalar joint using this approach. Does a posterior 2-portal approach allow for a complete freshening of the posterior subtalar joint? MATERIAL AND METHODS: Freshening was performed through an arthroscopic posterior 2-portal approach on 10 cadavers. The quality of bone freshening and proximity of the neurovascular structures to the posterior portals were subsequently evaluated by dissection. RESULTS: There was one partial laceration of the sural nerve. The posteromedial portal was 6.8mm (95% CI: 4.4 to 9.2) away from the posterior tibial vascular pedicle. The entire talar and calcaneal articular surfaces of the posterior subtalar joint were freshened. In eight of 10 cases (95% CI: 48 to 95%), the posteromedial process of the talus prevented contact between fragments. DISCUSSION: This study showed that the entire posterior subtalar joint can be freshened through an arthroscopic posterior 2-portal approach with little morbidity. LEVEL OF EVIDENCE: Level IV.

Component positioning in primary total hip replacement: a prospective comparative study of two anterolateral approaches, minimally invasive versus gluteus medius hemimyotomy.

INTRODUCTION: One factor of implant survivorship in total hip replacement (THR) is the quality of implant choice and positioning. The purported advantages of minimally invasive approaches are faster recovery, shorter hospital stay and less per-operative blood loss. On the other hand, there have been many reports of higher complication rates, and doubts as to the quality of implant positioning. HYPOTHESIS: The quest to minimize tissue damage is at the cost of THR positioning quality. OBJECTIVES: To assess implant positioning in a prospective comparative continuous multicenter series. PATIENTS AND METHODS: Between 2008 and 2009, a prospective comparative study was conducted on a continuous series of 141 THRs. Ninety-two were performed in two centers, using a minimally invasive Watson-Jones approach; the other 49, performed in a 3rd center, used an anterolateral approach with anterior hemimyotomy. The surgeons were in all cases experienced in their technique. Short-term follow-up comprised clinical and functional (Postel Merle d'Aubigné (PMA), Harris, SF12, WOMAC) and biological assessment (serum creatine phosphokinase (CPK), myoglobinemia, hematocrit) and analysis of complications and of implant positioning on X-ray and CT-scan. RESULTS: On the Watson-Jones approach, surgery time was longer; day-1 analgesic administration was lower; PMA, Harris and WOMAC scores were better at 6 weeks; and CPK levels were lower at 24 and 48hours. There were no significant differences on the other clinical and biological criteria. Implant positioning analysis revealed significantly greater combined anteversion and greater variation in acetabular inclination mean with the Watson-Jones approach, but no differences in cup positioning, femoral stem positioning, or limb length discrepancy. DISCUSSION: The minimally invasive Watson-Jones approach provided faster recovery and less muscular damage. However, implant positioning was less precise in terms of acetabular cup inclination. LEVEL OF EVIDENCE: Level III. Prospective, comparative, non-randomized.

Laxity measurements using stress radiography to assess anterior cruciate ligament tears.

INTRODUCTION: The clinical diagnosis of the anterior cruciate ligament (ACL) tear is based on demonstrating anterior subluxation of the tibia on the femur. In any of the following perspectives, diagnostic (cutoff value confirming rupture), prognostic (treatment efficacy), and therapeutic (laxity influencing the treatment), this laxity can be measured on stress X-rays. WORKING HYPOTHESIS: The diagnostic value of dynamic radiographs is low for ACL rupture. Passive Telos(®) X-rays have better diagnostic value, better radiologic quality, and are easier to carry out than active Franklin-type X-rays. MATERIAL AND METHODS: A cohort of 112 patients (28 females, 84 males; mean age, 33.7 years [range, 18-72 years]) with an indication for knee arthroscopy were studied prospectively. Before undergoing the arthroscopic treatment, two series of images of both knees were taken: one series of passive anterior drawer dynamic X-rays on a Telos(®) device at 250 N and a series of active anterior drawer dynamic X-rays according to Franklin (contraction of the quadriceps against 7 kg of weight at the ankle). The arthroscopic evaluation of the ACL (reference status) was compared to the anterior laxity measurements (absolute and differential) of each knee compartment (medial, lateral, and average) to determine the diagnostic value of the two radiological tests. RESULTS: We found 70 patients with an "arthroscopically ruptured ACL", 32 with an "arthroscopically healthy ACL", and 10 with a "partial rupture". The measurement of the anterior drawer values on the dynamic X-rays (active and passive) by two independent observers was reliable and reproducible (ICC>0.80), particularly when using the medial compartment (ICC=0.96) and the differential values eliminating the interobserver measurement error and interindividual laxity variations. In terms of X-ray technique, the active images were more frequently painful and the radiographic result showed less good quality than the Telos images. The anterior drawer values in the "healthy ACL" group were significantly less than in the "ruptured ACL" group for the Telos(®) images, whether the measurements were absolute or differential. For the Franklin images, this difference was only significant for the absolute values. Used for diagnosis (4-mm differential on the medial compartment), the passive dynamic images had lower diagnostic values (Se=59% and Sp=90%) than the series reported in the literature, which were marked by great heterogeneity. CONCLUSION: The measurement of anterior drawer values on Telos(®) and Franklin dynamic X-rays is a reliable and reproducible measurement, particularly when using the medial compartment and differential measurements. This small series did not demonstrate a diagnostic value for the Franklin images, contrary to the Telos(®) X-rays. Used for diagnostic purposes, the Telos(®) images had a low sensitivity; consequently, they should be used preferentially for prognostic or therapeutic purposes. LEVEL OF EVIDENCE: Level III, prospective case-control study.

[Thrombosis of the posterior tibial artery complicating closed injury of the ankle]. / Thrombose de l'artère tibiale postérieure: une complication rare d'un traumatisme fermé de la cheville.

Closed ankle injury without fracture is a common finding in the emergency room. Outcome is generally spontaneously favorable, the injury having no long-term clinical impact. Exceptionally, these injuries can be associated with arterial damage. We report a case of an apparently benign closed ankle injury which was found to be associated with serious arterial damage. Forced dorsal flexion of the ankle joint during a traffic accident caused an arterial lesion without any apparent damage to the bone and joints. The posterior tibial artery was interrupted leading to subacute ischemia of the foot. The diagnosis was established 17 days after trauma. Revascularization could not be achieved and leg amputation was necessary. This case illustrates the difficulties encountered in this type of vascular injury. Most cases in the literature have also involved late diagnosis with often serious clinical impact. Clinicians should be aware of this rare complication of apparently benign ankle injury because of the risk of major loss of function.

Anatomical comparative study of two vascularized bone grafts for the wrist.

Atrophic scaphoid non-union and lunate necrosis can be treated with vascularized bone grafting; through a posterior approach as described by Zaidemberg, based on a supraretinacular artery, or through an anterior approach, based on the volar carpal artery, according to Kuhlmann's procedure. The aim of our study was to determine the area covered by each of these two grafts and their respective future applications. Fifteen hands from eight adult human cadavers, free of any scar, were dissected after injection of colored fluid latex, through dorso-radial approach for Zaidemberg's graft and through volar approach for Kuhlmann's. We observed the morphological parameters of the pedicles and the arc of rotation of each flap. The volar vascularized graft had a constant origin and it could be transferred to the scaphoid, the lunate and the scapholunate joint. The posterior graft of Zaidemberg was technically more difficult to harvest because of the anatomical variations. It made it possible to reach the scaphoid, the trapezium and the scaphotrapeziotrapezoid joint line. Both these two vascularized bone grafts represent interesting procedures for treatment of scaphoid non-union or lunate necrosis, or intracarpal bones arthrodesis. They bring various possibilities of bone covering, related to specific area of mobilization and are not opposite procedures, but have different targeted indications. One must better define the respective places of the vascularized bone grafts, compared with the traditional free (non-vascularized) graft.