Functional Recovery Following Trapeziectomy and Ligament Reconstruction and Tendon Interposition: A Prospective Longitudinal Study.

PURPOSE: Patients undergoing surgery for trapeziometacarpal (TMC) joint arthritis require preoperative counseling on the expectations of surgery. This study aims to document the objective and functional recovery over the initial 12 months following trapeziectomy and ligament reconstruction with tendon interposition (LRTI). METHODS: We prospectively followed 55 patients with symptomatic TMC joint osteoarthritis after trapeziectomy and LRTI. Patients were assessed on functional outcome measures, pain, and objective outcomes of grip, tip and key pinch strength, and range of motion. Outcomes were recorded preoperatively and at 3, 6, 9, and 12 months after surgery. RESULTS: Outcome measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and pain, improved significantly after surgery at each 3-month interval up to 9 months. Palmar and radial abduction were significantly improved compared to their preoperative ranges, but opposition was unchanged. Power grip significantly exceeded the preoperative strength at 6 months and further increased at 9 months. Tip pinch significantly exceeded the preoperative strength at 12 months. There was no difference in the key pinch strength compared to the preoperative strength. CONCLUSIONS: Over a follow-up period of 12 months, trapeziectomy and LRTI is an effective treatment in significantly reducing pain in 80% of patients. Although normal patient-reported outcome measures of DASH and PRWE are not regained, when compared to normative values, these measures are significantly improved; the improvement plateaus at 9 months. Patients can expect to attain 37% and 46% of their eventual measured DASH and PRWE scores, respectively, at 3 months, and 82% and 79% of their eventual measured DASH and PRWE scores, respectively, at 6 months. Grip strength exceeded the preoperative strength by 15% at 6 months and by 30% at 9 months. Tip pinch strength significantly exceeded the preoperative strength by 20% at 9 months. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Robotic Surgery Simulator: Elements to Build a Training Program.

OBJECTIVE: Face, content, and construct validity of robotic surgery simulators were confirmed in the literature by several studies, but elements to build a training program are still lacking. The aim of our study was to validate a progressive training program and to assess according to prior surgical experience the amount of training needed with a robotic simulator to complete the program. DESIGN: Exercises using the Da Vinci Skill Simulator were chosen to ensure progressive learning. A new exercise could only be started if a minimal score of 80% was achieved in the prior one. The number of repetitions to achieve an exercise was not limited. We devised a "performance index" by calculating the ratio of the sum of scores for each exercise over the number of repetitions needed to complete the exercise with at least an 80% score. SETTING: The study took place at the François Baclesse Cancer Center. Participants all work at the primary care university Hospital located next to the cancer center. PARTICIPANTS: A total of 32 surgeons participated in the study- 2 experienced surgeons, 8 junior and 8 senior residents in surgery, 6 registrars, and 6 attending surgeons. RESULTS: There was no difference between junior and senior residents, whereas the registrars had better results (p < 0.0001). The registrars performed less exercise repetitions compared to the junior or senior residents (p = 0.012). Attending surgeons performed significantly more repetitions than registrars (p = 0.024), but they performed fewer repetitions than junior or senior residents with no statistical difference (p = 0.09). The registrars had a performance index of 50, which is the best result among all novice groups. Attending surgeons were between senior and junior residents with an index at 33.85. CONCLUSION: Choice of basic exercises to manipulate different elements of the robotic surgery console in a specific and progressive order enables rapid progress. The level of prior experience in laparoscopic surgery affects outcomes. More advanced laparoscopic expertise seems to slow down learning, surgeons having to "unlearn" to acquire a new technique.

Review of Acute Traumatic Closed Mallet Finger Injuries in Adults.

In adults, mallet finger is a traumatic zone I lesion of the extensor tendon with either tendon rupture or bony avulsion at the base of the distal phalanx. High-energy mechanisms of injury generally occur in young men, whereas lower energy mechanisms are observed in elderly women. The mechanism of injury is an axial load applied to a straight digit tip, which is then followed by passive extreme distal interphalangeal joint (DIPJ) hyperextension or hyperflexion. Mallet finger is diagnosed clinically, but an X-ray should always be performed. Tubiana's classification takes into account the size of the bony articular fragment and DIPJ subluxation. We propose to stage subluxated fractures as stage III if the subluxation is reducible with a splint and as stage IV if not. Left untreated, mallet finger becomes chronic and leads to a swan-neck deformity and DIPJ osteoarthritis. The goal of treatment is to restore active DIPJ extension. The results of a six- to eight-week conservative course of treatment with a DIPJ splint in slight hyperextension for tendon lesions or straight for bony avulsions depends on patient compliance. Surgical treatments vary in terms of the approach, the reduction technique, and the means of fixation. The risks involved are stiffness, septic arthritis, and osteoarthritis. Given the lack of consensus regarding indications for treatment, we propose to treat all cases of mallet finger with a dorsal glued splint except for stage IV mallet finger, which we treat with extra-articular pinning.

Renal cell carcinoma in functional renal graft: Toward ablative treatments.

The occurrence of a kidney transplant tumor is a rare but serious issue with a double risk: the return to dialysis and the development of metastatic cancer. Publications on this topic are mainly case reports. The purpose of this review was to report an exhaustive literature review of functional graft renal cell carcinomas to highlight the impact of tumors on the renal graft outcomes. 201 de novo renal carcinomas in functional renal grafts from 69 publications were included. Incidence was estimated at 0.18%. Graft tumors were mostly asymptomatic (85.9%). Whatever the discovery circumstances of graft tumors, they were mostly documented by graft ultrasounds supplemented by CT-scanning or MR imaging. Nephron sparing surgery (95 patients) was the first treatment performed followed by radiofrequency ablation (38 patients) and cryotherapy (10 patients). The most common tumor graft histology was clear cell carcinoma (46.4%), followed by papillary carcinoma (43.7%). Specific mortality was 2.9% with 6 deaths. Renal graft cell carcinoma is a rare pathology with a low specific death. When possible, conservative treatment should be the first choice.

Acetabular reconstruction using a free fibular autograft in total hip arthroplasty revisions.

PURPOSE: Acetabular reconstruction for segmentary bone loss aims for primary stability and long-lasting integration. The use of a fibular autograft has been described after tumour resection and in traumatology. The hypothesis of this study is that it offers a mechanically reliable solution with good functional results and acceptable morbidity. METHODS: This is a two center retrospective study of 26 operated hips. Indication was mechanical loosening in every case. The operative technique included fibular grafting of a segmental bone loss associated with an acetabular metal reinforcement. RESULTS: Mean follow up was 88 months (three to 165). The PMA score increased from 8.5 (five to 12) to 15 (six to 18) (p <0.001). Acetabular migration was 2 mm (0-4) vertically and 1 mm (0-2) medially. Three graft failures were observed. No major morbidity was observed. CONCLUSION: Fibular autograft after mechanical loosening and segmentary bone loss in total hip arthroplasty revisions offers a mechanically reliable solution for acetabular reconstruction. The results seem to be at least equivalent to other techniques.

Comparison of UW and Celsior: long-term results in kidney transplantation.

BACKGROUND: The aim of this study was to compare 2 preservation solutions in kidney transplant recipients in the same center during the same period since initiation of the use of High Na+; low K+ solution (Celsior). MATERIAL AND METHODS: From January 1999 to April 2011, 610 consecutive renal transplantations were done in our department with deceased donor kidneys. Data were collected prospectively. Organ procurement was performed in our center for 305 kidneys. We washed and preserved 409 kidneys in UW, and 201 in Celsior solution. RESULTS: Donors criteria were worse in the Celsior group for age, male sex, creatinemia, and cold ischemia. Populations of recipients were comparable. There were no differences at 1 and 12 months in creatinine levels (p=0.9 and 0.8, respectively) and in number of delayed graft functions (DGF) (p=0.8 and relative risk =0.9) between groups. There were no differences in post-transplantation outcomes for all variables. At 5 years, graft survival was 90.4% for UW and 93.5% for Celsior (p=0.44). CONCLUSIONS: Our retrospective study did not succeed in demonstrating superiority of a High Na+; low K+ solution compared to a UW type reference solution. Celsior has the same effectiveness as UW during kidney cold storage.

The high rate of de novo graft carcinomas in renal transplant recipients.

BACKGROUND: To investigate the incidence, the clinical characteristics and outcomes of renal graft carcinomas in the same renal transplant population. METHODS: From April 1989 to April 2012, 1,037 consecutive renal transplantations were performed in our department. Data were collected prospectively in an extensively maintained database. For all recipients, monitoring consisted of clinical examination and an abdominopelvic CT scan or ultrasonography at least once a year. RESULTS: After 1,037 renal transplantations, 48 men and 14 women (sex ratio 3:4) with a mean age of 54 years (25.1-78.9) were included for urological malignancies. Eight graft carcinomas were identified: 7 renal cell carcinomas (5 papillary carcinomas and 2 clear cell carcinomas of the renal graft) and 1 transitional cell carcinoma of the ureteral graft (incidence 0.78%). Nephron-sparing surgery was chosen for 5 patients with good outcomes. All graft renal cell carcinomas were classified as pT1a and the mean size of tumors was 28.4 mm (range 6-45). The 5-year specific survival rate was 100%. No recurrence was observed with a mean follow-up of 36.8 months (4.1-84.3). CONCLUSION: Thus confirming an increased risk of de novo graft cancer, close monitoring of renal transplant recipients should be discussed with at least an abdominopelvic ultrasonography and PSA measurement once a year. Renal cell graft carcinomas seemed to be mostly small and of papillary type and low grade.

Impact of renal graft nephrectomy on second kidney transplant survival.

PURPOSE: To determine the impact of non-functional renal graft nephrectomy on second kidney transplantation survival. METHODS: We performed a retrospective study on patients managed in our department from April 1989 to April 2011. We compared the number of acute graft rejections and graft survival between patients undergoing second transplantation with (Group I) or without (Group II) prior graft nephrectomy. RESULTS: A total of ninety-one patients received a second renal graft: 43 underwent graft nephrectomy and 48 kept their non-functional renal graft. There were 5 episodes of acute graft rejection in Group I and 12 in Group II (p = 0.3). Six (13.9 %) grafts failed in Group I and eight (16.6 %) in Group II. Five and 10 years actuarial graft survival in Group I were, respectively, 91 and 85 %, while in Group II were 82.7 % and 69 % (p = 0.2). PRA level and number of acute rejection episodes did not have a statistically significant influence on graft survival, whether the patient had a nephrectomy or not (p = 0.2). CONCLUSION: Nephrectomy of a failed allograft did not significantly improve the survival of a subsequent graft. Graft nephrectomy should be indicated in case of graft-related pain or a chronic inflammation syndrome.

Effects of graft pretensioning in anterior cruciate ligament reconstruction.

PURPOSE: Graft pretensioning is used in anterior cruciate ligament (ACL) reconstruction to prevent secondary slackening. Its effects on collagen fibrillar ultrastructure are not known. In this study, we hypothesized that graft pretensioning in ACL reconstruction creates ultrastructural changes detectable in scanning electron microscopy (SEM). METHODS: A prospective comparative study was carried out on 38 ACL reconstructions using a 4-strand semitendinosus graft. Samples were harvested intra-operatively before and after pretensioning for 30 s, 2 or 5 min. The images produced in SEM were analyzed using an original semi-quantitative «CIP¼ score taking into account collagen cohesion, integrity, and parallelism. Intra- and inter-tester reliability for the CIP score were tested. RESULTS: The CIP scores decreased by 3.5 (1.6) points after pretensioning (P < 0.05). Significant differences were found in the 5, 2 min and 30 s subgroups for the global CIP score. Relative decrease (Delta CIP) was significantly higher in the 2 and 5 min subgroups after pretensioning in comparison with the 30 s subgroups. Intra- and inter-tester reliability for the CIP score were 0.85 and 0.92 (P < 0.05). CONCLUSION: Pretensioning ACL grafts resulted in alteration of the collagen fibrillar ultrastructure, detectable using SEM. These results confirm the existence of collagen ultrastructural changes after pretensioning that may be related to its duration. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Pyrocarbon interposition wrist arthroplasty in the treatment of failed wrist procedures.

Treatment of failures after prior wrist surgeries with major articular destruction is challenging. In most cases, total wrist fusion is the only possible salvage procedure. We propose a new interposition arthroplasty with a pyrocarbon implant called Amandys. A total of 16 patients, 14 men and 2 women, with a mean age of 56 years were operated on for a failure of wrist surgery performed previously, with an average time lapse of 12 years. The prior surgeries were partial wrist arthrodesis in seven cases, silicone implant interpositions in five cases, advanced Kienböck disease (Lichtman IV) treatment in two cases, proximal row carpectomy in one case, and an isolated scaphoidectomy in one case. A prospective study with clinical and radiological evaluation was performed with a mean follow-up of 24 months (6 to 41 months). Pain and function showed significant improvement. The mean pain score decreased from 7 of 10 to 4 of 10, postoperatively. The mean grip strength was 19 kg (53% of the contralateral side), and the mean range of motion in flexion extension was 68 degrees. Mean strength and range of motion did not change significantly with the operation. The mean QuickDASH (Disability Arm Shoulder and Hand) score decreased from 59 of 100 to 39 of 100. The mean Patient-Rated Wrist Evaluation decreased from 57 of 100 to 33. Two patients (12.5%) required revision for implant repositioning. No dislocation or subsidence of the implant was noted. Pyrocarbon interposition arthroplasty is a new option for treatment of advanced wrist destruction. Preliminary short-term results suggest that it may be a reliable alternative to total wrist fusion. The level of evidence of this study is IV (therapeutic case series).

Change in posture control after recent knee anterior cruciate ligament reconstruction?

The aim of this study was to compare statical postures of a knee anterior cruciate ligament reconstruction (ACLR) population with a healthy control population. Thirty-five patients (age 25.5 +/- 5.8 years) were compared at 15 days after an anterior cruciate ligament reconstruction with 35 healthy, age and sex-matched subjects. Bilateral and unilateral postures were studied according to various stances, knee extension and 20 degrees knee flexion with opened and closed eyes, using a stabilometric platform. A comparison with the non-ACLR limb and the healthy limbs of the control population was carried out. The ACLR subjects present with the following: (i) a significant change in two-legged stance, i.e. distances covered by the centre of pressure projection are significantly increased; (ii) a postural alteration during the ACLR one-legged stance with knee extension and opened eyes in comparison with the non-ACLR limb; (iii) an incapacity for certain ACLR subjects to perform one-legged stance on the non-ACLR limb when there is no visual compensation. Only 11.4% (95% CI: 0.9-21.9%) and 42.8% (95% CI: 26.3-59.3%) of ACLR subjects are capable of maintaining correctly a one-legged stance posture with closed eyes on both sides (knee extension and flexion, respectively). The identification of the ACLR knee limb is possible from the one-legged stance postural test in knee extension and opened eyes condition. Because of a change in two-legged balance and of the incapacity for certain ACLR subjects to maintain one-legged stance with closed eyes, a central origin explaining the abnormalities of postural control is suggested.

Congenital isolated midline sinus of the upper lip: clinical and embryological approaches.

OBJECTIVES: Congenital sinuses or fistulas of the lip are uncommon malformations, yet true medial upper-lip fistulas (MULFs) are extremely rare. We present a new case of congenital upper-lip fistula located in the midline of the philtrum of an 8-month-old girl. INTERVENTION: Complete surgical removal was performed with a combined extra- and intraoral approach. Histological examination revealed that the fistula was lined by squamous epithelium with sebaceous and mucous glands and hair follicles. RESULTS: Several embryological hypotheses have been proposed concerning these anomalies. This article reexamines and discusses major embryological theories on pathogenesis of sinuses or fistulas of the upper lip. We propose that early ectodermal inclusion events may occur in the medial fusion area during formation of the intermaxillary process. This embryological approach is highly concordant with our recent hypothesis on nasal dermoid sinus cysts (NDSCs) pathogenesis, in which we proposed an embryological hypothesis with early ectodermal inclusion phenomenon in the midline suture area to explain NDSCs pathogenesis. CONCLUSIONS: Common early ectodermal inclusion phenomena could be involved in both NDSCs and MULFs pathogenesis.