[Free dermal fat graft for coverage of the median nerve following failed carpal tunnel release]. / Le greffon dermohypodermique pour la couverture du nerf médian au poignet: résultats cliniques et paracliniques.

OBJECTIVES: We wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release. METHODS: Eight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI). RESULTS: Five patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13 kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases. CONCLUSIONS: Free dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results.

[Mycobacterium marinum tenosynovitis of the abductors]. / Ténosynovite des fléchisseurs à Mycobacterium marinum.

INTRODUCTION: Infection with Mycobacterium marinum is rare and usually produces cutaneous lesions. We report here two cases of tenosynovitis of abductor muscles. CASE: The first case presented isolated involvement of the abductors of the left thumb, and the second the abductors of the middle finger. In both cases, the bacteriological examinations found M. marinum. Antibiotic therapy for three months with rifampin and clarithromycin cured the infection. DISCUSSION: These cases of tenosynovitis followed deep inoculation. A mycobacterial infection should be considered in cases of synovitis, especially when limited to an area of the hand in patients without other rheumatic disorders.

[Treatment of complex hand injuries by stable osteosynthesis using a "multiple pinning" technique]. / Ostéosynthèse stable dans le traitement des mains complexes par le "brochage multiple".

UNLABELLED: The multiple pinning technique has been reported by the authors as an effective method for the treatment of comminuted osteo-articular fractures of the digits. This procedure can be performed rapidly, offers good stability and thereby allows early post-operative physiotherapy. The aim of this type of management is to offer the patient recovery of thumb to digit pinch by restoring two functional joints (MCP, PIP) or at least one functional joint (MCP), particularly as far as the radial digits are concerned. TECHNIQUE: After performing reduction, very small diameter pins are introduced and the bone fragments are reconstructed like a puzzle. The very small calibre of the pins allows multiple pinning and simultaneously permits them to be easily orientated. The pins being multiple, and parallel or diverging are responsible for the stability of the construct. The ends of the pins are either bent over or more frequently, just cut flush with the surface of the bone. Comminuted fractures, even the most severe, respond very nicely to this management. DISCUSSION: The multiple pinning technique offers remarkable stability, allowing early post-operative physiotherapy. This technique is particularly effective when faced with the difficulties of treating open fractures of the metacarpals and phalanges. Moreover, this technique avoids performing an extensive skin incision. The stability of this multiple pinning technique could be related to the following factors: the shortness of the pins offering more rigidity and less flexibility, the proper fixation of the pins within the cortical bone, especially in the diaphysis and the large number of pins offering more strength. The disadvantage of this technique is the possibility of pin migration.

[Vascularized fibular transplant for avascular necrosis of the femoral head: 16 cases]. / Evolution anatomo-radiographique des nécroses avasculaires de la tête fémorale traitées par transplant fibulaire vascularisé. A propos de 16 cas.

PURPOSE OF THE STUDY: We report our experience with vascularized fibular transplant using the technique described by Urbaniak for the treatment of avascular necrosis of the femoral head. MATERIAL AND METHODS: Sixteen patients, mean age 39 years 4 months at surgery, were evaluated at mean 3 years 6 months follow-up (minimum 15 months). Mean pain score (analog visual scale) was 6.25/10. Mean Postel-Merle-d'Aubigné (PMA) function score was 12. The Ficat classification was grade 2A (n=9) or grade 2B (n=7). RESULTS: There were no cases of infection or migration of the fibula. The only complication at the donor site was one case of paresia of the long extensor of the hallux which resolved spontaneously. There were five failures which required a hip prosthesis (31%). Three failures occurred early during the first 18 months. Two were late. These patients had grade 2B (n=4) or grade 2A (n=1) necrosis. At last follow-up, eleven hips had not required prosthetic revision (69%). The pain score improved in 81% of patients: mean score=2.3. Nine patients were satisfied or very satisfied (81%). Among these eleven hips, function was good or excellent in eight (72%). Walking distance was improved in nine patients, unchanged in one and worse in one. Joint motion improved in nine patients, was unchanged in one and decreased in one. Nine patients resumed their full-time job. Mean sick leave was 13.3 months. Radiographically, only two of the initial Ficat grade 2A hips remained at this stage. Likewise only one of the three hips initially rated grade 2B remained at this stage. Overall radiographic results were: failure (n=5), worsening (n=9), stabilization and no improvement (n=2). Among the nine 2A hips, one was converted to a total hip prosthesis and five femoral heads remained spheric. Among the seven 2B hips, four were converted to a total hip prosthesis and two femoral heads collapsed. DISCUSSION: At mean follow-up (3.5 years), 69% of the hips had not required total hip arthroplasty. The grade 2A hips did better but the small sample size did not allow statistical comparison. There was a clear discordance between the clinical presentation and the radiographic findings among the hips which were not treated with a prosthesis: good function score, maintained occupational and daily life activities contrasting with unfavorable radiographic evolution. Results could be improved by detailed quantification of the lesion using 3D imaging and by associating intraoperative navigation.

[Surgical correction of fifth finger permanent abduction by tenodesis. Preliminary cadaver study]. / Correction chirurgicale de l'abduction permanente du cinquième doigt par ténodèse. Etude préliminaire cadavérique.

Permanent abduction of the little finger can be responsible for daily embarrassment in patients with an ulnar nerve palsy. To correct this deformity, active transfers are usually performed utilising the extensor tendons of the hand. Because of the anatomical variability of the extensor system of the hand, these active transfers can be responsible for postoperative loss of full extension of the little finger. Analysis of the orientation of the forces generated by these transfers shows that they are only weak adductors. A surgical technique using tenodesis is proposed in this preliminary study. This tenodesis has the objective of increasing the adductive forces on the little finger without an extensor tendon transfer. The advantages and disadvantages of this technique are discussed. A clinical evaluation will be undertaken at a later date to confirm the reliability of this technique.

[Long gamma nail for the treatment of subtrochanteric fracture of the femur]. / Enclouage par clou gamma long dans les fractures sous-trochantériennes et trochantéro-diaphysaires du fémur de l'adulte.

PURPOSE OF THE STUDY: The standard gamma nail is commonly used for the treatment of trochanteric fractures but cannot be used if the fracture lies at the level of the distal locking. Theoretically, the long gamma nail would overcome this inconvenience and could be used for all cases of subtrochanteric and trochanteric-shaft fractures. MATERIAL AND METHODS: Clinical and radiological charts were established in 1990 for a multicentric study. The radiology work-up included an AP view of the pelvis and an oblique lateral view of the hip. Two classifications were used: Seinsheimer and Muller as modified by Nazarian. Three stages of fracture reduction were recorded: 1=anatomic reduction, 2=acceptable reduction, 3=poor reduction. From January 1995 to December 1999, 46 patients were treated with the long gamma nail. Twenty-four cases were excluded for various reasons (from which 3 early death). 22 remaining patients were followed for more than six months. Mean age was 68 years (range 42-96); there were six women and 16 men. Ten patients were traffic or work accident victims and 12 had had a home accident. RESULTS: Mean duration of surgery was 70 minutes. Three patients required revision surgery within a week of the initial osteosynthesis. Mean hemoglobin level before surgery was 12.9 g/dl; 8.9 g/dl during the first postoperative week. Mean hospital stay was 14 days. Weight-bearing with support was possible early after surgery in 16 patients who walked with crutches or a walker. Mean delay to weight-bearing was 11 days. At three months, all patients were using an aid for walking; at six months, four patients used a walker. Bone healing was achieved on the average at the twelfth week. Radiological reduction was anatomic in four, acceptable in three and poor in 15. DISCUSSION: We advocate the AO classification as it allows a structured analysis of all fractures within a unique system. We compared our results with nine series reported in the literature using other therapeutic methods (screw-plate, nail-plate, Ender nail). The operative time for the long gamma nail (70 min) was comparable with that for other surgical techniques. Treatment with the long gamma nail favors bone healing and limits the risk of infection. Radiological results in our series were poor, but there were no cases with nonunion and the morbidity was low.