Long-term function after pseudo-pollicization of the little finger.

This article presents a technique for facilitating use of pinch between the ring and little fingers for use in rare cases of congenital absence, or severe hypoplasia, of the thumb in which pollicization of the index finger is impossible, or not advised because the child is already pinching by scissor action between the ring and little fingers. The technique avoids drawing attention to the hand, as is the case after true pollicization of the little finger. The technique was used in five hands in five children. Three of the patients could only be followed for under 2 years. Two patients were available for longer follow-up of 6 years and 2 months and 3 years after surgery. The surgery was shown to facilitate opening of the web and pinch between the little and ring finger tips, and continues to be of functional value to the children as they grow.

[Early physiolysis in the correction of clinodactyly]. / La physiolyse précoce dans la correction de la clinodactylie.

The principle of early treatment by physiolysis without osteotomy is based on the removal of the deforming tether. We retrospectively studied the effects of early physiolysis on the growth and correction of deformity with a minimal follow-up of 6 years in 17 cases. The mean correction at follow-up was 82% of the pre-operative angle. All operated phalanges had grown. There was no epiphyseal closure. Full correction (residual deformity of less than 10 degrees) was achieved in 11 patients. No patients needed closing osteotomy for insufficient correction. We think that early physiolysis is a quick operation which provides growth and at least partial correction of the clinodactyly.

[Flexion deformities of the thumb: clasped thumb and trigger thumb]. / Déformation en flexion du pouce de l'enfant: pouce flexus adductus et pouce à ressaut.

Congenital clasped thumb in palm corresponds to a spectrum of anomalies leading to a loss of thumb extension and abduction. Intrinsic muscles and skin shortening are not infrequent. Conservative orthopedic treatment should be undergone as soon as possible. When this treatment fails, or when patients are seen late, surgical correction has to be customized according to the involved structures. The trigger thumb is 10 times more frequent than the trigger finger. It is bilateral in 30% of the cases. The term "congenital" remains unclear as several investigations on newborns have not evidenced trigger thumb. In children, it is very rare to find a real trigger and presentation consists in a fixed flexion deformity of the interphalangeal joint. Diagnosis is clinical, with a palpable nodule at the level of T1 pulley. Conservative treatment, consisting in a nocturnal splint, is indicated before the age of two years old. After this age, or in case of failure of splinting, surgery will be needed.

["Principalisation" of pollicization in congenital conditions. Technical modifications for functional and aesthetic improvement]. / Cahier des charges en vue d'améliorer l'aspect esthétique et fonctionnel de la pollicisation dans les différences congénitales. Propositions techniques.

After reviewing our experience of pollicization in congenital differences, we found that classical techniques have several weak points concerning function and appearance. Abduction is frequently insufficient and adduction quite weak. Aesthetically, the thumb has a slender aspect and the web fold is absent and the commissure looks more as a cleft. We tried to " principalize" the issues to propose some technical modifications for improvement of function and appearance.

Vesicle trafficking during sporozoite development in Plasmodium berghei: ultrastructural evidence for a novel trafficking mechanism.

Oocysts from Anopheles stephensi mosquitoes fed on murine blood infected with Plasmodium berghei berghei, were fixed for electron microscopy 6-12 days post-feeding. Ultrastructural analysis focused on Golgi-related trafficking pathways for rhoptry and microneme formation during sporogony. A small Golgi complex of 1-3 cisternae is formed close to the spindle pole body from coated vesicles budded from the nuclear envelope which is confluent with the endoplasmic reticulum. Rhoptries begin as small spheroidal bodies apparently formed by fusion of Golgi-derived vesicles, lengthening to 3-4 microm, and increasing in number to 4 per sporozoite. Ultrastructural data indicate the presence of a novel mechanism for vesicle transport between the Golgi complex and rhoptries along a longitudinal 30 nm - thick fibre (rootlet fibre or tigelle). Filamentous links between vesicles and rootlet indicate that this is a previously undescribed vesicle transport organelle. Genesis of micronemes occurs late in bud maturation and starts as spheroidal dense-cored vesicles (pro-micronemes), transforming to their mature bottle-like shape as they move apically. Filamentous links also occur between micronemes and subpellicular microtubules, indicating that as in merozoites, micronemes are trafficked actively along these structures.

Anterior tenoarthrolysis for severe flexion contracture of the fingers (the "TATA" operation): a review of 50 cases.

The "hook finger", with both proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion contractures, often after multiple previous operations, is difficult to treat. This paper reports the results of 50 fingers in 49 patients in which the TATA (Téno-Arthrolyse Totale Antérieure) salvage procedure, described by Saffar in 1978, was carried out. Thirty-seven of 50 (74%) of these fingers had had at least one previous operation, most on the flexor apparatus. The mean PIP and DIP extension deficit pre-operatively was 133 degrees with a mean PIP lag of extension of 83 degrees . With a mean follow-up of 7.8 years, 45 fingers were improved, five were not and none was worsened. The mean PIP and DIP extension deficit postoperatively was 47 degrees , with a mean PIP lack of extension of 31 degrees . The overall gain in extension deficit of both joints was 86 degrees and of the PIP was 52 degrees . One PIP joint developed septic arthritis immediately after surgery. The benefit of this salvage operation is mainly in the change of the active range of motion to a more functional arc.

Conservative treatment versus scaphotrapeziotrapezoid arthrodesis for Kienbock's disease. A retrospective study.

Efficiency of surgical treatment in Kienböck's disease has never been proven in the long term. We retrospectively reviewed the charts of the 104 patients treated by various techniques for Kienböck's disease from 1981 to 1999 in our unit. A comparison was made between 19 cases treated conservatively (amongst 59) and 11 cases (amongst 25) treated by scaphotrapeziotrapezoid (STT) arthrodesis with a mean follow-up of 13 years. The two groups were statistically comparable in stage, age, sex ratio, number of manual workers. STT arthrodesis was responsible for an increased loss of mobility, an increase of barometric pain, a longer rehabilitation time and more fractures of lunatum than conservative treatment. Those results question about indications for STT in Kienböck's disease.

[Thumb reconstruction in emergency, not including replantation]. / La reconstruction en urgence du pouce, à l'exception de la replantation.

Many articles have discussed secondary thumb reconstruction but only few have been devoted to acute reconstruction. We propose to artificially separate four circumstances: (i) the thumb is preservable without associated trauma of the fingers. The rule is not to burn the bridge of secondary reconstruction; (ii) the thumb is preservable but a neighboring finger is seriously injured and functionally condemned. The finger has to be used as a "bank" to borrow the necessary anatomical structures for reconstruction of the thumb; (iii) the thumb is not preservable and the lesions of a neighboring finger allow to use it for a pollicization. The difficult decision is between the immediate transposition or maintenance for secondary pollicization. Only finger devascularization is a clear indication for acute pollicization; (iv) Finally when the thumb is not preservable and there is no associate finger injury, it is difficult to assess and inform sufficiently the patient to take a decision. Secondary thumb reconstruction is the best choice.

[Joint denervations in hand surgery: a plea]. / Dénervations articulaires en chirurgie de la main: un plaidoyer.

Since the original description of wrist denervation, the principle of joint denervation in hand surgery has been extended to other joints like the first carpometacarpal, interphalangeal and metacarpophalangeal joints. At the wrist level as at the digital level, the results are comparable to those obtained with other surgical alternatives. In case of unsatisfactory results, a more traditional intervention remains always possible.

Pollicization in congenital differences.

Pollicization of the index finger is a well established procedure for some cases of thumb hypoplasia. We reviewed our experience of 27 "normal" index-finger pollicizations with a mean follow-up of seven years, excluding those cases with more extensive radial hypoplasia and abnormal fingers. Even in such an "ideal" situation, strength was deceptive and the frequently slender aspect of the new thumb with quite extensive dorsal scar formation and the "cleft" appearance of the first web disappointing. In a prospective series of 32 cases, we tried to improve both the function and appearance of the thumb by modifying the classical incision as well as the transferred muscles and tendons.

[Technical note: ulnar "pseudo-pollicisation" in congenital hand differences]. / La technique de "pseudo-pollicisation" dans les différences congénitales.

In certain rare cases of thumb aplasia or hypoplasia, pollicisation of the second finger is not recommended or impossible. It happens when the most radial fingers are hypoplastic or abnormal or when an ulnar prehension pattern has already developed. In these cases, if functional, pollicisation of the most ulnar finger in not suitable because of the ugly cosmetic result. In order to combine the functional advantages of the ulnar pollicisation with a satisfactory cosmetic appearance, the authors describe pseudo-ulnar pollicisation by supination osteotomy. This operation combines rotation of the fifth ray with the establishment of a larger web space between the two most ulnar fingers. We have used this technique in five preliminary cases with a minimum follow-up of 18 months.

[The ulnar longitudinal deficiency: proposition of a descriptive classification]. / Déficiences longitudinales ulnaires: proposition d'une classification descriptive.

Ulnar longitudinal deficiency is an extended malformation sometimes involving the whole upper extremity, even including sometimes the opposite side. The clinical and radiological aspects are variable and none of the existing classifications takes into account all the possible deformities. Multiple decisive factors in the surgical indications are missing such as shoulder stability, elbow position (extension or flexion with or without pterygium), orientation of the hand (internal rotation), wrist inclination and number of digits. Based on a review of our 46 clinical cases as well as the published cases in the literature we have developed a simple way to describe each level.

Percutaneous needle aponeurotomy: complications and results.

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

[The "candlestick" technique for the correction of certain types of congenital metacarpal synotosis]. / La technique dite "du chandelier" pour la correction de certains types de synostose métacarpienne congénitale.

Metacarpal synostosis is a rare congenital hand malformation requiring only occasionally a surgical correction. However in case of divergent epiphyses there is a progressive accentuation of the deformity. In the "Y" type of symmetrical synostosis, the authors propose a trapezoidal osteotomy with upside down relocation allowing realignement of the epiphyses without distant bone donor site.

[Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases]. / Dénervation trapézométacarpienne. Description de la technique chirurgicale et résultats préliminaires dans une série prospective de 14 cas.

INTRODUCTION: The main goal of first carpometacarpal arthritis surgical treatment is to relieve pain. The main disadvantages of the usual techniques (trapeziectomy, implant arthroplasty) are loss of strength or presence of a prosthetic device. It is difficult to propose such extensive surgery at an early stage of the disease. Selective denervation of the first carpometacarpal joint seems to be an interesting choice. We propose a new technique of denervation based on our previous anatomical investigations. TECHNIQUE: Two incisions are needed to cut all the articular branches derive from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve and the lateral ante brachial cutaneous nerve. MATERIAL: Fourteen patients were prospectively included in our study with a mean follow-up of 5 months. RESULTS: Pain relief was very satisfying in 12 cases (mean decrease 84%). An increase in grip and key pinch strength was noted. Complications were uncommon, excepted temporary paresthésia in the radial nerve area. DISCUSSION: This technique seems to be promising and a good indication for patients with no disabling deformity, but only long-term results will confirm the place of denervation in the treatment of first carpometacarpal arthritis.

The nerve supply of the trapeziometacarpal joint.

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint.

[Secondary treatment of digital mutilations: reconstruction or amputation]. / Le traitement secondaire des mutilations digitales: reconstruction ou amputation.

Decision for stump improvement, shortening or reconstruction after finger mutilation is based on multiple factors. Some of them belong to the patient, age, psychological background, job and leisure activities and cosmetic expectation. Others belong to the injury, its mechanism and the anatomical lesions. Abstention, prostheses and rehabilitation are among the options. Conventional techniques are not to be forgotten as age remains an ultimate frontier in microsurgical reconstruction to obtain a good sensory result. Function and appearance are closely linked for a useful and a used hand.