Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique.

The aim of this work was to analyze the results of a percutaneous drainage technique with 2 catheters during surgical treatment of phlegmons of the finger flexor tendon sheath. Our series included 32 patients with a phlegmon of flexor tendon sheaths, including 19 men and 13 women, mean age 43.4years. The first 16 patients (group I) were treated by a conventional open technique for the lavage and drainage of the affected tendon sheath. The last 16 (group II) were treated by an ultrasound-guided percutaneous lavage technique with 2 catheters: one proximal and one distal. In the case of impermeability of the digital canal, conversion by open technique was carried out. In group II, the ultrasound-guided percutaneous lavage was 5 times successful. Failure of the proximal catheter alone was noted once, whereas failure of the distal catheter alone was noted 7 times. The failure of both catheters was noted 3 times. At a mean follow-up of 19.7 days, mean handgrip strength was 56.5% compared to the contralateral side in group I and 82% in group II (P<0.05). However, there was no significant difference for pain, QuickDASH, total active mobility between group I and group II. Pain was at 1.4/10 for group I and 1.4/10 for group II. QuickDASH was measured at 27/100 for group I and 22.27/100 for group II. Total active mobility was 227° for group I and 243° for group II. In conclusion, surgical treatment of the phlegmons of the finger flexor tendon sheath with an ultrasound-guided percutaneous lavage technique gives significantly better short-term grip strength than the conventional open technique.

Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study.

The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis.

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

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.

Active extensor indicis proprius extension strength after its use as a tendon transfer: 19 cases.

Complications following extensor indicis proprius (EIP) tendon transfer are loss of strength, independence and mobility in the index finger in extension. The main goal of this study was to measure the index finger's independent and dependent extension strength after a tendon transfer. Secondary goals were to determine if the index finger retained the ability to extend independently after the transfer and to evaluate second metacarpophalangeal (MCP) joint mobility. Our study consisted of 19 patients in whom the EIP tendon had been divided proximally to the extensor hood. The EIP tendon was retrieved through a proximal approach at the distal radius level and rerouted towards a recipient tendon. At an average follow-up of 41 months, the average independent extension strength was 5.6N versus 11N on the contralateral side and the dependent strength was 10.9N versus 20N. No patient complained of a loss of extension strength and all had retained independent active extension on the operated index finger. The second MCP joint on the operated side had an independent extension lag of 15.3° compared to the contralateral healthy side and a dependent extension lag of 0.2°. Two patients were impaired in their daily activities when moving the operated index finger. Our results show that EIP harvesting for tendon transfer leads to decreased independent and dependent strength as well as decreased active extension of the second MCP joint. However, the functional impact was negligible and should not compromise the use of the EIP as a tendon transfer. LEVEL OF EVIDENCE: III.

Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture.

The prognosis of isolated volar plate sprains of the proximal interphalangeal (PIP) joint is related to the extension deficit. Some consider an associated avulsion fracture as a sign of severity. The goal of this study was to find out whether the outcomes of conservative treatment in PIP volar plate injury was impacted by the presence of an avulsion fracture. Our series included 75 patients, 27 years old on average, of which 58 were men. All sprains were stable. The X-rays were normal in 52 cases (group 1); an avulsion fracture was found in 23 cases (group 2). The patients were treated by buddy taping during the day and a straight finger splint at night for 3 weeks. At the last follow-up, no significant difference was found between the two groups regarding pain, extension/flexion range of motion or edema. The results of this study show that the prognosis of conservative treatment of PIP volar plate injuries does not depend on the presence of an avulsion fracture.

Is there a relevance of suction drainage in non-septic wrist surgery?

INTRODUCTION: No rational argument leads to conclude to the benefit or the innocuousness of drainage in non-septic wrist surgery. HYPOTHESIS: The goal of this study was to validate the hypothesis that for those indications drainage is unnecessary. MATERIAL AND METHOD: We reviewed 1001 consecutive cases, concerning 885 patients, 58 years old in average. RESULTS: Out of 1001 procedures, 9 patients were operated on both sides, 145 were operated twice of which 130 for the implantation and then the removal of surgical material. None were reoperated for hematomas. Three patients were initially treated for an osteosynthesis using an anterior plate of distal radius and secondarily reoperated due to sepsis, one of them twice. The material was removed from two patients. The average time of tourniquet for those 3 osteosynthesis was significantly superior (84.33min) to the average time for the 595 other anterior distal radius plates (45.35min). CONCLUSION: The results of our study show that suction drainage in non-septic wrist surgery is unnecessary. LEVEL OF EVIDENCE: III descriptive retrospective study.

Establishing a reproducible protocol for measuring index active extension strength.

The goal of this study was to establish a reproducible protocol to measure active extension strength in the index finger. The secondary objectives consisted in correlating the independent or associated index extension strength to the other fingers force of contraction of the extensor indicis propius with hand dominance. The population studied consisted of 24 healthy volunteers, including 19 women and 20 right-handed individuals. The independent and dependent index extension strength in each hand was measured three times with a dynamometer by three examiners at Day 0 and again at Day 7. Intra and inter-examiner reproducibility were, respectively, >0.90 and >0.75 in all cases. The independent extension strength was lower than the dependent one. There was no difference between the independent index extension strength on the dominant and non-dominant sides. The same was true for the dependent strength. Our results show that our protocol is reproducible in measuring independent and dependent index extension strength. Dominance did not come into account. LEVEL OF EVIDENCE: II.

Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy.

PURPOSE: Some authors have proposed performing proximal row carpectomy (PRC) as the initial treatment for perilunate dislocations. HYPOTHESIS: The goal of this retrospective study was to compare the results of a cohort of perilunate dislocation cases that were operated by open reduction and internal fixation (ORIF) or by PRC between 2006 and 2011. METHODS: The cohort consisted of 21 men with a mean age of 33years, who either had an isolated perilunate dislocation (7 cases) or a fracture-dislocation (14 cases). All dislocations were dorsal, with 10 stage I and 12 stage II. Thirteen patients had been treated by ORIF (group 1) a mean of 1.2days after the injury. Eight patients had been treated by PRC (group 2) a mean of 18.7days after the injury. Immobilization time was 6-12weeks in group 1 and 2weeks in group 2. RESULTS: The mean operative time was 95minutes in group 1 and 65minutes in group 2. After a mean follow-up of 35months, the following outcomes were found for groups 1 and 2, respectively: pain 3/10 and 1/10, strength 77% and 73%, strength in supination 79% and 93%, strength in pronation 67% and 95%, QuickDASH 27/100 and 16/100, PRWE 43/150 and 15.5/150, flexion 69% and 57%, extension 84% and 58%, pronation 97% and 103%, supination 98% and 97%. There were four cases of osteoarthritis in both groups. CONCLUSION: Treatment of acute perilunate dislocations by PRC leads to medium-term results that are at least as good as those with ORIF treatment. The surgery duration is shorter with PRC, as is the immobilization period. TYPE OF STUDY: Retrospective comparative. LEVEL OF EVIDENCE: III.

Treatment of unstable distal phalanx fractures by extra-articular DIP pinning: A series of 12 cases.

Unstable distal phalanx fractures are typically treated by pinning of the distal phalanx or the distal interphalangeal joint (DIP). Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. To limit these complications, we wanted to explore the benefits of using locked extra-articular DIP pinning. The cohort consisted of 12 patients (mean age 36.3 years) who had an extra-articular (6 cases) or intra-articular distal phalanx fracture (6 cases). All patients were treated surgically with a construct consisting of two connected K-wires: one was placed inside the shaft of the distal phalanx and the other was placed perpendicular to the middle phalanx. The K-wires were removed after 1 month. After an average follow-up of 19.9 weeks, pain was 0.4/10 and the QuickDASH score was 7.41/100 on average. The range of motion was, on average, 30.0° less than the contralateral uninjured side for active flexion, 8.8° less for active extension, 32.0° less for passive flexion and 4.1° less for passive extension. The overall hand strength averaged 85.2% of the contralateral one. One secondary displacement occurred but there were no infections. In all, these findings suggest that locked extra-articular DIP pinning is a simple and reproducible surgical treatment for distal phalanx fractures. LEVEL OF EVIDENCE: IV.

Proximodistal interphalangeal arthrodesis of the little finger: A series of 7 cases.

As an alternative to amputation of the little finger, we report here seven cases of shortening arthrodesis carried out by resecting the middle phalanx and proximodistal interphalangeal (PDIP) arthrodesis. Our cohort consisted of 6 males and 1 female (58years average age), with a stiff little finger secondary to Dupuytren's disease or trauma. All fingers were approached dorsally; after resection of the middle phalanx and decortication of the subchondral bone, fusion of the remaining phalanges was performed using an intramedullary self-breaking screw-pin. At a mean follow-up of 34.9months, pain decreased significantly (1.4/10 versus 5.4/100 preoperatively), the QuickDASH score improved significantly (33/100 versus 51/100 preoperatively) and all the joints had fused. One patient suffered from cold intolerance. PDIP arthrodesis is an alternative salvage procedure to amputation for multioperated stiff little fingers that does not burn any bridges if it fails.

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.

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.