Open volar radiocarpal dislocation with extensive dorsal ligament and extensor tendon damage: A case report and review of literature.

The authors present the case of a patient with a rare combination of open volar radiocarpal dislocation and complete destruction of the dorsal capsule-ligament complex and tendons. The treatment consisted of open reduction and arthrorisis (temporary arthrodesis during 45 days) with four K-wires (radiocarpal and radioulnar). The capsule-ligament complex was fixed with anchors and the extensor tendons were repaired by suturing. A long-arm cast was applied for six weeks. After an 18-month follow-up, the Cooney-modified Green and O'Brien score was 70 and the wrist range of motion was 85°. Dynamic intraoperative X-rays are needed to look for bone or ligament (intracarpal or radioulnocarpal) injuries. Arthrography, arthroscopy or MRI may provide additional information. In cases of stable lesions without intracarpal ligament injuries, conservative treatment may be sufficient. Otherwise, surgical treatment is required, using temporary external fixation or arthrorisis (temporary arthrodesis) associated with anatomic repair of capsular ligaments. The average duration of postoperative immobilization is 6.6 weeks. An external fixator seems to be useful for reduction and for placing optimal tension on repaired ligament repair. Twenty-three cases of volar radiocarpal dislocation are described in published studies. None of them was associated with bone, tendon, skin or capsule-ligament complex injuries. Few studies describe the long-term functional and radiological outcomes of these injuries.

High-energy injuries of the wrist.

High-energy injuries to the wrist gather complex fractures of the distal radius, radiocarpal dislocations, perilunate dislocations, and other intracarpal dislocations. Depending on the energy of the injury and the position of the wrist at the time of impact, the patient, often a young male with a high functional demand, presents one of these injuries associating fracture(s) and ligament injury. The trauma is often bilateral, with proximal lesions (elbow) very often associated with contusion or compression of the median nerve. Diagnosis is confirmed by wrist X-rays, which are sufficient to determine treatment for radiocarpal and perilunate dislocations. In cases of distal radius fractures or other intracarpal dislocations, a preoperative CT is necessary. Reduction of the dislocation and relief of neurovascular compression are performed immediately. The final treatment of each lesion (bone fixation, ligament repair) can be undertaken simultaneously or delayed, depending on the patient and the lesions. Cartilage lesions, resulting from the high-energy injury, can be estimated using arthroscopy but cannot be repaired and determine the prognosis. The surgeon's objective is to restore joint congruence, which does not prevent stiffness, the main complication of these rare injuries, which the surgeon must know how to recognize and treat.

Fixation of distal radius fractures in adults: a review.

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

Fixation of split anterior tibialis tendon transfer by anchorage to the base of the 5th metatarsal bone.

Split anterior tibialis transfer is a procedure, frequently performed in combination with triceps surae lengthening, to treat equinovarus foot deformity in adult hemiplegia patients. The authors present their surgical technique, with tendon fixation by an anchor to the base of the fifth metatarsal. Although bone-tendon anchor fixation is widespread in orthopedic surgery, it is original in this type of indication. It is simpler, and less traumatic for the bone than a bone tunnel and less traumatic for the sole than transplantar fixation. The very distal attachment to the base of the 5th metatarsal bone solves the common problem of adjusting the tension of tendon transfer. The authors report their experience of 22 split transfers from 2005 to 2008.

[Opened dorsal metacarpophalangeal dislocation of the four long fingers. Volar plates reinsertion with anchors]. / Luxation dorsale ouverte métacarpophalangienne des quatre doigts longs. Réinsertion des plaques palmaires par ancres.

The authors describe the case of a 53 year-old right-handed patient, who fell from a scaffolding and sustained a dorsal metacarpophalangeal dislocation of the four long fingers of his left hand. Because of the major dorsal instability after reduction, a mini anchor was placed over each metacarpal neck, to help repair the volar plate. After active rehabilitation, the patient regained satisfying articular amplitudes and was able to get back to his job and his regular sports activities.

Treatment of trapeziometacarpal osteoarthritis by partial trapeziectomy and costal cartilage autograft. A review of 100 cases.

PURPOSE: Trapeziectomy remains the surgery of choice in the treatment of trapeziometacarpal osteoarthritis. Some authors consider the collapse of the trapezial space responsible for a loss of strength and intracarpal deformities. We report our experience of partial trapeziectomy with chondrocostal autograft as an interposition material. METHODS: The study included100 thumbs in 82 patients with a mean age of 64.6 years (47-82). Mean follow-up was 68 months (4-159). Partial trapeziectomy was carried out through a dorsal approach. The graft was harvested through a direct approach of the 9th rib. RESULTS: Our results were similar to those obtained with alternative techniques, except for strength where the gain is improved. No intracarpal deformities were seen. There was no sign of graft wear; the length of the thumb ray is preserved. The results are stable over time, and the morbidity of the costal donor site is negligible. The interposition of a hardwearing biological material and its association with partial trapeziectomy enable to restore the thumb stability and strength.

Anatomical and radiological study applied to distal radius surgery.

PURPOSE: The purpose of this study was to determine, during anterior plating of the distal radius, the length of a screw above which there is a risk for the extensor tendons and the optimal shape of an anterior plate. It was also to determine the projection of the axis of the distal third of the radius on the distal articular surface in case of wrist arthroplasty in order to simplify the procedure. METHODS: We studied 74 dry radii from adult cadavers. Each one underwent a CT scan. We measured the thickness of each radius at the dorsal tubercle level, at the second compartment level and at the third compartment level. We calculated the metaphyseal-epiphyseal angles of the lateral column and of the intermediate column (Rikli and Regazzoni in J Bone Joint Surg (Br) 78(4):588-592, 1996). We also calculated the projection of the longitudinal axis of the most distal 7 cm of the radius on the distal carpal surface of the radius. RESULTS: Mean thickness at the dorsal tubercle level was 22.1 mm (18-26.1). The mean slope of the lateral column was 155° (143-167) while that of the intermediate column was 145° (134-153). We have found a statistically significant difference (p < 0.0001) between these two slopes. The axis of the distal radius was projected on the posterior-lateral quadrant of the distal articular surface. CONCLUSIONS: The emergence of new implants needs a precise evaluation of a fractured, an arthritic or a reconstructed distal radius. The double slope of the distal radius complicates the manufacturing of an "anatomical" plate. The optimal shape is between these two slopes. Moreover, ancillaries for wrist replacement are still approximations, which means that it is important to know the projection of the radial axis on the articular surface of the distal radius.

[Osteoarthritis of the trapeziometacarpal joint in men: different stakes. Results of three surgical techniques]. / La rhizarthrose chez l'homme: des enjeux différents. Résultats de trois techniques chirurgicales.

Basal thumb arthritis is less common in men, but the functional implication is different in this manual worker or active retired population. The objective was to analyse the results of three surgical procedure in an exclusively men's population. Twenty-eight patients (19 partial trapeziectomy with interposition of a chondrocostal autograft, seven total trapeziectomy and two prosthesis), with a mean age of 69 years old, were reviewed at a mean follow-up of 71 months. Mobility and pain were similar in the three populations. But the strength and Dash scores were better in the cartilage group. Radiologically the length of the thumb ray was greater in the cartilage group and no signs of loosening were observed in the prosthesis group. The surgery of reference in this population is the arthrodesis of the trapeziometacarpal joint. But the lack of mobility is disabling, the strength is questionable and painlessness varies due to high rates of non-union. Only one study compared four surgical procedures in an exclusively male population and total trapeziectomy seemed to give the best results. But this technique carries risk of shortening of the thumb ray. Even if the comparison is difficult, the association of partial trapeziectomy with interposition of costal cartilage graft seems to give better stability to the thumb column by preserving length as well as greater strength compared to total trapeziectomy. We advocate this procedure for basal thumb arthritis in men.

[Distal radius fracture with dorsal displacement: correlation between functional score, reduction quality and fixation]. / Fractures du radius distal à déplacement dorsal: corrélation entre scores fonctionnels, qualité de réduction et type de fixation.

Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement). Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates (20 patients mean age 59.9 years [range 25-87 years]), intra- and extrafocal pinning (22 patients mean age 55.6 years [range 17-83 years]), the anterior plate (20 patients mean age 57.1 years [range 17-78 years]). An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the Chi-square test for non-continuous variables. P<0.05 was considered significant. Mean operative time was equivalent for the two plates fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), DASH score, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for pronation-supination and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base. For these extra-articular fractures, pinning can provide good functional results like anterior plating but each treatment has advantages that functional analysis detected.

Extra-articular distal radius malunion: The phosphate cement alternative.

UNLABELLED: Five consecutive patients (mean age: 40.4 yrs (range, 19-58 yrs)), with symptomatic distal radius malunion underwent corrective opening wedge osteotomy using phosphate cement as an alternative to bone autograft, at a mean 9 months (4-16mo) of fracture. Internal fixation used a plate placed just above the distal radioulnar joint, with soft-tissue release. Radiographic and functional parameters were measured before surgery, and at 6 months and 1 year. At a mean 32.4 months (range, 16-47mo), all patients were satisfied and all the osteotomies were united. At 1 year's follow-up, wrist range of motion reached 75% compared to the contralateral side. Two biopsies performed during plate removal showed osteoid tissue at the cement-bone junction. It is reasonable to consider injectable phosphate cement as a viable alternative to bone grafting in conjunction with surgical correction of distal radius malunion. LEVEL OF EVIDENCE: level IV.

[Addition of antithrombosis in situ in the case of digital replantation: preliminary prospective study of 13 cases]. / Adjonction d'antithrombotiques in situ en cas de replantation digitale: étude prospective préliminaire de 13 cas.

Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.

[The flexor digitorum superficialis flap in treatment of neuroma in continuity of the median nerve]. / Le lambeau de fléchisseur superficiel des doigts dans le traitement des névromes en continuité du nerf médian.

The purpose of the study was to evaluate the flexor digitorum superficialis flap in treatment of neuroma-in-continuity of the median nerve at the wrist. We reviewed six patients operated from September 2000 to March 2007. In all cases, daily disabling pain has been significantly reduced. Four patients are very satisfied. It is a local flap, easy to harvest with few morbidity. We compare it with the various options described for this pathology.

Influenza virus hemagglutinin stimulates the protein kinase C activity of human polymorphonuclear leucocytes.

Human polymorphonuclear leukocytes (PMNL) incubated with influenza virus, A/USSR/90/77 (H1N1) or its hemagglutinin produced a significant increase in their PKC activity when compared with untreated PMNL. The activated kinase translocated from cytosol to cellular membrane. The calcium-dependent enzyme activity was inhibited by a specific inhibitor suggesting that alpha and/or beta isoforms of PKC were involved.