Graner's procedure in Kienböck disease: a series of four cases with 25years of follow-up.

UNLABELLED: Advanced stages of Kienböck's disease are treated by several techniques, one of which is Graner's procedure, nearly abandoned nowadays. The results of long-term follow-up of a series of four cases Graner's procedure are presented. Four patients were reviewed with a follow-up of 25years. There were two women and two men mean aged 37years at the time of surgery. Two of them were manual workers. Graner's procedure was the first surgery in three cases and secondary to failure of radius shortening in one case of Stage IIIa. Three patients underwent bone healing and the fourth benefited secondarily from radiocarpal arthrodesis. At maximal follow-up, the mean DASH score was 36.6 and pain assessed by visual analogic scale was 3.25 out of 10; the range of movement was half of the opposite side; the wrist strength was 80.9% of the opposite side. In the three consolidated cases, a spontaneous remodeling of the radiocarpal articular surfaces was noted. Graner's procedure is logical as it aims at creating a new radiocarpal articulation, either by the fusion of the lunate with the capitate (Graner I) or by replacing the lunate with the head of the capitate (Graner II and III). However, this old procedure should no longer be one of the surgical procedures for Kienböck disease due to its drawbacks: necrosis or non-union of the head of the capitate, necessity to perform a wrist fusion in the long-term and side effects of bone graft harvesting. LEVEL OF EVIDENCE: II. Retrospective study.

[Treatment of mallet finger with dorsal nail glued splint: retrospective analysis of 270 cases]. / Traitement du doigt en maillet par orthèse dorsale collée.

PURPOSE OF THE STUDY: Management of mallet finger is both difficult and controversial. Sequelae are not uncommon, particularly after surgical treatment. Many authors advocate orthopedic treatment which is less invasive but requires greater patient participation to implement. Despite the large number of orthopedic methods proposed, none has proven superiority. We report here our experience with a dorsal adhesive splint which preserves digital pulp function and improves observance. MATERIAL AND METHODS: This retrospective analysis included 270 mallet fingers presenting 153 tendon injuries and 117 bony injuries in 265 patients aged 42 years on average and treated from 2003 to 2005. Most of the tendon injuries involved the medius (38.7%) and most of the bony injuries involved the ring finger (35.4%). A splint was fashioned for the two distal phalanges and glued to the nail plate filed for this purpose. The splint was fashioned out of an L-shaped plastic sheet of thermo-malleable plastic dipped in hot water (60 degrees C). The L was molded to the dorsal aspect of the phalanges and rolled like a ring around the second phalanx, then glued to the nail. The splint was worn for eight weeks by patients with a tendon injury and six weeks for those with a bony injury. The splint was then worn at night for two weeks. Three criteria were used to analyze outcome: residual extension deficit, joint involvement, complications. RESULTS: Mean follow-up was 18 months. Mean time from trauma to definitive installation of the splint was six days. The complication rate for this orthopedic method was 14.3%, complications being observed in 6% of patients. All complications were transient except for one case of swan neck deformity and one case of painful osteoarthritis. Thirty splints (11%) became unglued but were all reinstalled using the same protocol. Thirty fingers (14%) presented residual deficit of active extension measuring less than 20 degrees. The quality of the result depended on the type of injury: tendon injuries led to extension deficit in more fingers (20% versus 7.5%) but for a lesser degree (16.5 degrees versus 19.1 degrees) than bony injuries. DISCUSSION: We observed a lower rate of complications with this technique than usually reported in the literature. Transient ungueal dystrophy only involved 2.5% of the fingers in our series. Swan neck was observed in only 8.3% of the fingers, all with tendon injuries, and resolved in all. There was only one case of symptomatic distal interphalangeal joint degeneration among the 117 fingers with bony injuries. There were no cases of skin necrosis. The results of this retrospective study, with mean 2.38 degrees extension deficit, are better than reported in other series in the literature. These results suggest that surgical indications for mallet finger should be revisited, irrespective of the type of injury, excepting when subluxation persists despite installation of the splint. CONCLUSION: In conclusion, our series demonstrates that the adhesive dorsal splint is an effective treatment for all types of mallet finger, reducing the number of indications for surgery. Compared with other techniques, the advantages are: free digital pulp, better patient observance, lesser extension deficit.

Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach.

In a prospective study, eight consecutive patients with nine ruptures of the distal biceps tendon underwent repair through a single incision. All patients were satisfied with their clinical results and had full ranges of elbow and forearm motion. There were no radial nerve injuries and no radio-ulnar synostoses. Isokinetic testing, after correction for dominance, demonstrated a 6% strength deficit, but 7% higher endurance in the repaired extremity for the flexion-concentric test, and no strength deficit and 13% higher endurance for supination. The improved endurance is probably explained by initial reduced effort due to apprehension which minimized subsequent fatigue.

[Eight days of hand emergencies. Report of the audit carried out at the FESUM centers from June 3 to June 9, 2002]. / Huit jours d'urgences mains. Rapport de l'audit réalisé dans les centres FESUM du 3 au 9 juin 2002.

All the FESUM centers in France, Belgium and Switzerland were invited to participate in this prospective audit, during 1 week in June 2002. In these FESUM centers, the patients are operated by senior hand surgeons or trainees graduated with a microsurgical and a hand surgery University degrees. All acute hand disorders, requiring surgery or not, were to be included. For every case, a standardized form was to be filled. This form included 22 fields concerning the specificities of the patient, the circumstances of the accident, the lesions and initial treatment up to exit of the patient out of the Hand Center. Out of the 43 French centers, 38 (90%) participated in this study, but only 30% in the other French speaking countries. A total of 2360 forms were completed and analyzed, representing a mean of 8 forms per day center (6-147). The population was predominantly active men with a mean age of 31. Manual workers represented 41%, scholars 33%. Most of them came to the Hand Center with a non-specilized vehicle (86%). Emergency medical transportation was required in 130 cases (5.8%). A majority of the patients were treated on an outdoor basis. A 1-day admission concerned 29% of the patients, and 4.6% have been admitted on an indoor basis during several days. Work accident represented 28% of all the cases, while the majority was daily living (62%) or sport (15%) accidents. Closed trauma represented 50% of the cases. Amongst open trauma (974 cases), 862 were simple skin lacerations, 156 skin loss, 140 extensor tendon lacerations, 70 flexor tendon lacerations. A preliminary wound exploration had been performed in a non-specialized center in 124 cases (12%). Complete amputation of some part was observed in 33 cases. In 32%, the initial severity of the lesion led to expect some degree of definitive consequences. Some kind of anesthesia was required in 43% of the cases (local in 41%, troncular in 19%, plexical in 28% and general in 9%). A surgical procedure was performed in 45% of the patients. Microsurgery was necessary in 15%, six of which were replantations. The period between presentation to the Hand Center and treatment was less than 1 day in 95% of the cases. Time of treatment was considered to be delayed in 113 cases (5%). Following this audit, it is considered that the FESUM centers make provision for the care of 120,000 cases per year, 54,000 of which needing a surgical procedure. This may be a small part of the total load of emergency hand surgery throughout the country (generally estimated over 1.4 million), but compares quite favorably with other European studies. We believe that improvement relies essentially on a better orientation of the patients whether they need a simple skill or specialist skill treatment. An information leaflet about orientation of hand trauma has been distributed to non-specialized emergency centers. Hand surgery training must be reevaluated inside the universitary system to avoid a dramatic lack of hand surgeons within a few years. A new audit will be presented next year.

[Medical responsibility in hand traumatology]. / Responsabilité médicale en traumatologie de la main.

The apparently benign nature of many hand injuries may lead one to underestimate the potentially serious consequences of these injuries. In case of significant residuals, patients may consider themselves victims of inadequate treatment. The traumatic lesions may be classified into three groups of increasing severity (mild, moderate and severe emergencies) which require the services of increasingly sophisticated treatment teams: Services d'Accueil des Urgences (SAU) (general emergency care facilities) for minor injuries, general surgery emergency services for more severe injuries, and specialized teams such as the centers of the "Fédération Européenne des Services Urgences Mains" (FESUM) for serious complicated injuries. This differentiation is correlated to the level of expertise of the treatment team and the quality of the technical support at their disposition. Proper match of the severity of injury with the level of expertise of the treatment team can minimize the incidence of poor results and resultant litigation. Personalized treatment given with the informed consent of the patient, and his understanding that all necessary resources will be utilized, will lessen the tendency for the patient to consider some less than perfect results as the consequence of inadequate care, and therefore, lessen the likelihood of litigation against the physician or hospital. The evaluation of the permanent impairment should be analyzed as the difference between the actual result and similar, if not strictly identical cases given the appropriate level of treatment. In order to limit the frequency of litigation, including unjustified lawsuits, it is necessary, as a preventive measure, to integrate these precautions into the plan for provision of care for hand injuries.

[Arteriovenous dysplasia of the hand. A case report and attempts at conservative therapy]. / Arteriovenöse Dysplasie an der Hand. Ein Fallbericht und konservative Therapieversuche.

We present a 44-year old man with an hemorrhagic dorsal skin wound of the left ring finger, which after angiography led to the diagnosis of an arteriovenous dysplasia with fistulas involving the whole left forearm and hand. The local problem was successfully treated by surgical hemostasis and skin flaps, but the underlying vascular pathology seems to be untreatable. Compressive gloves as used in burn treatment are a simple help in this particular case.

The free vascularised fibular transfer as a definitive treatment in femoral septic non-unions.

Free vascularised bone transfer (fibula, iliac crest, or rib) is an accepted method of bone grafting in malignant and non-union bone surgery. The vascular microanastomoses have transformed the bone healing by creeping substitution seen after non-vascularised grafting (a long and often insufficient process) into normal healing of the fracture site. The presence of its own vascular support allows bone healing in such compromised circumstances as sclerosis and infection. We present the clinical history of five patients with septic femoral non-unions, in which only the final vascular fibular graft provided an acceptable outcome. Discussion about the indication and timing of this microsurgical salvage procedure is still controversial.

[Surgical treatment of fractures of the distal radius--a closed therapy concept. Initial results with the bowl osteosynthesis]. / Die operative Behandlung distaler Radiusfrakturen--ein geschlossenes Therapiekonzept. Erste Ergebnisse mit der Kelchosteosynthese.

We present our treatment strategy for distal radius fractures, based on intrafocal pinning (Kapandji) and further combination with a palmar plate resulting in bowl osteosynthesis (Nonnenmacher). Even with a changing surgical team, we got more than 80% good results and rapid revalidation. We thus favor dynamic minimal osteosynthesis close to the fracture physiopathology. Indication for external fixation becomes limited to open or comminutive fractures.

[Intrafocal wire fixation of wrist fractures. The original Kapandji technique. Course. Review of 400 cases]. / Brochage intra-focal des fractures du poignet. Technique originelle de Kapandji. Evolution. Revue de 400 cas.

Dynamic intrafocal pin fixation, first described by Kapandji for extra-articular fractures is an elegant solution for consolidating wrist fractures with posterior compression. We reviewed our experience using this method with 400 patients, confirming the validity of the method when applied rigorously. Globally, there is a correlation between the radiological findings and the quality of the clinical results which were satisfactory in 90% of the cases analyzed. Indications now include many joint fractures as a three-pin intrafocal fixation is performed. There is also the risk of creating an associated anterior comminution (either by trauma or iatrogenic) causing inadapted calus formation by secondary impaction, often with severe affects on the lower radio-cubital area. To avoid this inconvenience, we propose aasociating pin fixation with anterior internal fixation by an anterior plate. Analyzing 50 cases seen after consolidation confirmed the importance of this complementary fixation. Thus multiple fixation maintains good joint alignment without final compression leading to the quality results obtained.

[The De La Caffinière trapezo-metacarpal prosthesis in rhizarthrosis of the thumb. Apropos of 20 cases surgically treated between 1978 and 1990]. / Prosthèses trapézo-métacarpiennes De La Caffinière dans la rhizarthrose du pouce. A propos de vingt cas opérés entre 1978 et 1990.

The authors have studied twenty total prosthesis of de la Caffinière. These prostheses have been inserted between 1980 and 1990 at the "centre de Traumatologie et d'Orthopédie de Strasbourg", following a trapezo-metacarpal arthritis. According to a post-operative average of five years, the results are good in 70% cases. A study of the mobility and of the strength of the hand, as well as one of the radiography, allows to make bring out two complications: the first, rarely studied for this prosthesis, is a rigidity of the trapezo-metacarpal articulation due to post-operative ossifications. Consequently the post-operative ossifications. Consequently the post-operative benefit decreases proportionally to the importance of the rigidity; the second, already pointed out in few articles, is the presence of radio lucent lines which is asymptomatic in 20% of cases. The causes founded are different from the one already published. Anyway, in spite of those risks, it is globally useful in the majority of cases. Therefore the authors remain loyal to this intervention in the presence of an isolated trapezio metacarpal arthritis to the patients with are not subjected to handicrafts.

Aneurysmal cyst of the proximal radius: resection and free vascularized fibular bone graft.

We present the case of a 22-year-old woman with an aneurysmal cyst of the right proximal radius, treated by resection and a free bone graft (microvascular fibular transfer), without recurrence after 4 years. Over a 4 month period, there was a rapidly expanding and lytic lesion found in the radius. There were symptoms of elbow and wrist pain and early radially innervated muscle weakness. Radiological examination showed a localized tumour of the proximal radius, type 2, grade C, according to the classification of Campanacci. Biopsy led to the diagnosis of an aneurysmal bone cyst. Complete tumour resection was followed by a free vascularized fibular bone graft, resulting in good functional improvement, without local recurrence. Aneurysmal bone cysts are a rare condition, and the location in the radius has not previously been described. Vascularized bone grafts are mechanically and biologically superior in this type of case.

[Role of intrafocal pinning in the treatment of wrist fractures]. / Place du brochage intra-focal dans le traitement des fractures du poignet.

We have treated 350 displaced Colles fractures by percutaneous fixation with K wires arranged in a 'basket' formation, as described by Kapandji. This technique enables satisfactory stabilisation of the fragments and early mobilisation and rehabilitation, usually without the use of a plaster cast or brace. We describe our indications for use of the method, the technique followed and analyse our results.

[Intrafocal wiring of fractures of the wrist joint]. / Intrafokale Verdrahtung bei Handgelenkfrakturen.

This method discussed by Kapandji (1976) in which pins are passed through the fracture line and not through the styloid process provides dynamic pinning in comminuted fractures in the adult resulting from compression and extension. No plaster is used. The authors report the experience of the unit of hand surgery in the Centre de Traumatologie et d'Orthopédie of Strasbourg (150 cases at present). They describe the technique and the indications.

Fractures of the radial head and lesions of the lower radius and ulna in the adult: the importance of the prosthesis in resection.

Multi-fragmentary fracture of the head of radius is a common lesion of the elbow; and resection of the head is justified either in isolation or to be completed with prosthetic implant replacement. From a study of 25 hospital records of patients treated at the Orthopedic and Traumatology Center of CRAM of Strasbourg with an average post-operative follow-up of 8 years, it appears that the habitual complications secondary to simple resection of the radial head, in particular cubitus-valgus, ascension of radial shaft and dysfunction of the inferior radio-ulnar articulation, are not observed after prosthetic replacement. Furthermore, whenever an injury of the latter articulation exists concomitant with radial head trauma, no further secondary aggravation ensues following replacement. Arthroplasty seems to be, hence, at the present moment the operation of choice for serious fractures of the radial head in cases where osteosynthesis is not possible and which used to be indications for simple resection.

Osteosynthesis of fractures of the base of the first metacarpal by an external fixator.

Among the various methods for treating fractures of the base of the first metacarpal, use of the external fixator appears to be of interest for it maintains a satisfactory reduction while respecting the arch of the first web interspace as well as allowing early mobilization of all joints not involved in the injury. The miniaturization of the material, today possible, facilitates its use. The experience with 20 cases gained at the CTO de la CRAM de Strasbourg is presented. The authors discuss the utilization of the method, the practical means of doing it and their results. Its limitations are indicated as well as its special indications in comminuted and compound fractures.

[Intracarpal revascularization arthrodesis with transposition of the capitate bone (Graner type II)]. / Arthrodèse intracarpienne de revascularisation avec transposition du grand os (Graner type II).

Necrosis of the lunate requires surgery when it is painful and disabling. Decoulx's stage III is too often beyond reconstructive surgery (lengthening of the ulna, shortening of the radius), while such disabling procedures as wrist arthrodesis are not indicated yet. The intracarpal revascularizing arthrodesis with transposition of the capitate (described by Graner in 1966) is to be considered at this stage. The creation of a new condylar arch coated with cartilage, resembling the physiologic arch, and the preservation of the radio-carpal mobility, allows the return of sufficient motion and strength for everyday needs. The wrist often gets painfree; this procedure should thus be considered as a palliative salvage operation, none the less useful in young manual workers.