Upper limb surgery for tetraplegia: assessment of a 10-point strategy.

PURPOSE: Palliative motor surgery of the tetraplegic upper limb is well-defined, with relatively precise indications that however vary somewhat from team to team. Our personal indications originated mainly from Zancolli, and were applied by the same surgeon in two independent rehabilitation centers. The goals of this study were to assess the application of these indications with time. METHODS: Our retrospective study included three parts: summarization of our initial indications into a 10-point reference strategy; gathering the medical records related to all of the tetraplegic upper limb operations from 1989 to 2006, except for those related to complications and/or salvage procedures. For each patient, collected data corresponded to the 10 strategic points (SP); comparison of the collected data with the reference strategy, upper limb by upper limb, point by point, in order to identify and document any deviations. RESULTS: We assessed the use of the reference strategy in 272 consecutive operations (139 upper limbs, 96 patients). Overall nonconformity rate with the use of the 10-point strategy was 27% (38/139). Except for one very atypical case, all of the exceptions from the reference strategy were due to specific anatomical or physiological conditions. CONCLUSIONS: Our reference strategy has remained noticeably stable over time. However, three important evolutionary modifications occurred: systematic choice of biceps instead of deltoid to restore elbow extension; addition of the split distal flexor pollicis longus tenodesis procedure; and removal of extensor carpi radialis brevis from the list of potential flexor pollicis longus motors. Two issues, dealing with the systematic use of lassos and with brachio radialis to extensor digitorum communis transfer, are likely to be revisited in the future.

[Satisfaction with technological equipment in individuals with tetraplegia following spinal cord injury]. / Enquête de satisfaction sur l'équipement technologique des personnes tétraplégiques par blessure medullaire.

OBJECTIVE: To measure the acquisition, use and satisfaction with high technology equipment by spinal cord injured tetraplegic subjects. DESIGN AND SETTING: A questionnaire was mailed to 102 tetraplegic subjects who were hospitalised in the rehabilitation center of Kerpape (Ploemeur, France) between 1998 and 2004, and 59 subjects responded. The questionnaire asked about the use of telephones, computers, wheelchairs and environmental controls at home. RESULTS: When a piece of equipment was acquired, it was very often used. Patient satisfaction with equipment was 79.3%. Home phones and mobile phones were often used with options such as hands-free devices (78 and 59% respectively). A total of 64.4% of subjects acquired a manual wheelchair and 61% a power wheelchair. The most commonly acquired options on the power wheelchairs were the powered recline (73,7%) and tilt (71,1%) systems. All options were used but all were more desired than acquired. A total of 27.1% of subjects desired a pushrim-activated power-assist wheelchair, but only 15.3% had acquired one; 695% of subjects had a computer. Communication was the first use for the computer (82.5%); 49.2% of subjects had acquired an environmental control system, but 20% desired one. The first reason for lack of acquisition was financial difficulties but also accessibility and information problems. The factor that influenced the acquisition and need for equipment was the degree of spinal cord injury. No other factor reduced patient satisfaction with equipment. CONCLUSION: Patients were satisfied with the equipment they acquired. But their needs, especially wheelchair options and environmental control systems, were not satisfied.

[Extensor tenodesis to the retinaculum extensorum: anatomic and biomechanical study]. / Ténodèse des extenseurs sur le retinaculum extensorum: étude anatomique et biomécanique.

INTRODUCTION: The extensor tenodesis is a direct dynamic tenodesis which is activated by wrist flexion due either to hand weight or flexor carpi radialis. This tenodesis is usually performed to the distal radius, but it is possible to fix EDC (extensor digitorum communis) to the retinaculum extensorum. MATERIAL AND METHODS: Biomechanical study concerned 12 anatomical subjects (24 wrists). The biometric and radiological analysis of retinaculum displacement distalwards was made under low (1 kg) and moderate (6 kg) pulling. Surgical clips were placed on the proximal and distal limits of the retinaculum in order to study their positions on roentgenograms. RESULTS: Average width of the retinaculum was 19 mm. Average movement under 1 kg drive was 6 mm and 8.6 mm under 6 kg drive. X-rays showed that the proximal border of the retinaculum was always located proximally to the wrist rotate centre, whatever the traction. DISCUSSION: We found the same anatomical features described by different authors, except for the width of the retinaculum. Our study suggests that the retinaculum is strong enough to support a surgical tenodesis.

[Cup and cone arthrodesis of the thumb in palliative surgery for tetraplegia. Retrospective study of 57 cases]. / Arthrodèse cône-cupule des articulations du pouce dans la chirurgie palliative du tétraplégique. Etude rétrospective de 57 cas.

INTRODUCTION: The cup and cone technique, first described by Carrol and Hill is very simple. It affords excellent contact between bones, and allows all possible adjustments of the arthrodesis in three planes before its final fixation. MATERIAL AND METHODS: Fifty seven cup and cone arthrodesis of the thumb were performed in 41 adult tetraplegic patients. Level of arthrodesis was i.p. in 28 cases, TM in 25 cases and MP in 4 cases. Distribution in Giens classification was 3 group 1, 14 group 2, 9 group 3, 23 group 5, 2 group 6, 1 group 7, 2 group 10. Mean follow-up was 51 months. Three criteria were retrospectively studied: the clinical strength of arthrodesis, its position, and the potential existence of complications. RESULTS: Clinical fusion was obtained in 8 week in all cases, without any infection. No delayed union was observed. In only one case, a surgical revision was required, due to initial bad setting of TM arthrodesis and an intermetacarpal arthrodesis was performed with a bony graft. In all other cases, position of arthrodesis was correct. In a few cases, only minor or non specific drawbacks were observed: TM arthrodesis were sometimes painful during the first 6 months postoperatively; transient dystrophy of the thumb nail occurred two times in i.p. arthrodesis; the worst drawback was the shortening of the thumb, which impaired the key-grip in cases where the thumb was preoperatively short. DISCUSSION: In tetraplegic patients, stabilization of the thumb can be obtained either by split distal FPL tenodesis or by an arthrodesis at TM, MP or i.p. level of the thumb. When the provided thumb length is adequate arthrodesis is preferred. The cup and cone technique is very simple and effective. It is fit particularly in tertraplegic patients, whatever the level of the thumb arthrodesis.

[Survival of tetraplegic spinal cord injured persons after the first admission of a rehabilitation center and prognosis factors: a multicenter study of 697 subjects in French centers]. / La survie des blessés médullaires tétraplégiques après la première entrée en centre de rééducation et ses facteurs pronostiques.

BACKGROUND: We surveyed survival and prognosis factors in tetraplegic spinal cord injured persons (TSCI) after their admission to a physical medicine and rehabilitation center. METHODS: This multicenter study included 697 individuals, the entire cohort of patients admitted to three of the principal French centers caring for spinal cord injured persons from 1949 to 1997. The data set was drawn from the medical files and included data on the accident and its complications, social and demographic features, and the characteristics of the spinal injury. Survival data were obtained for all subjects from the official registries of their place of birth. Univariate (Kaplan-Meier) and multivariate (Cox regression) analysis was made to study links between these data and survival. RESULTS: Univariate analysis indicated that the principal variables significantly related to survival were: level of the lesion, age at the time of the accident, the cause of the accident, and the presence of a permanent tracheotomy or a depressive syndrome requiring medical care. Multivariate analysis showed that the risk of dying was 82% lower for persons who did not have a permanent tracheotomy. The risk declined by 92%, 89% and 69% for TSCI aged 20 years or less, 20-39 years and 40-59 years respectively at the time of the accident compared with those aged more than 60 years. This risk was 37% lower for TSCI without depressive syndrome and 52% lower for persons injured at levels C6, C7, C8 compared with those injured at levels C2, C3, C4. CONCLUSION: Multivariate analysis showed that the principal prognosis factors for survival are the presence of a permanent tracheotomy, the age at the time of the accident, the presence of a depressive syndrome and the level of the lesion. No statistical improvement of survival was observed related with time (corresponding to the year of inclusion) but, over the study period, there was an increasing number of spinal cord injured person who survived with high lesions.

The Tetrafigap Survey on the long-term outcome of tetraplegic spinal cord injured individuals: Part I. Protocol and methodology.

The Tetrafigap Survey, a multicentre epidemiological survey on the outcome of tetraplegic spinal cord injured (TSCI) people from their first admission to a Rehabilitation Department or Centre is currently being undertaken in France. The general objective of this survey is to evaluate the situation of the TSCI people and their conditions of life in its medical, psychological and social aspects. This first article is aimed at presenting the protocol and the methodology of this survey. In a second part, yet to be submitted for publication, the preliminary results will be presented. It was first necessary to create a database of the population of TSCI people known to the centres and medical rehabilitation services, removing double entries. The criteria used for inclusion in the study were: a complete or incomplete traumatic cervical cord lesion, including post-surgical complications; age 16 or over at the time of the accident which must have occurred before December 31, 1992. The enquiry consisted of a self-administered questionnaire carried out with surviving tetraplegic people who had given their informed consent for their participation. The questionnaire consecutively covered the following topics: the situation at the time of the accident, the medical evolution between the accident and the end of stay in a rehabilitation unit, their evolution after discharge and the current situation (medical, social, professional and personal). During this first phase, 6082 TSCI people were identified by the collaborating centres. The 603 files of those who had died and 769 double entries were removed. Thus, 4710 questionnaires were sent out. The results of the participation show that 2251 people gave their consent and received questionnaires (340 additional deaths were acknowledged at this step). 163 refused, 869 were lost for follow-up, and 67 were excluded. There was no reply from 1020 people. We received 1830 questionnaires of which 1669 fulfilled all the necessary criteria for data exploitation. Home interviews with people who gave their consent will be carried out in a second phase as well as a study of deaths. A 5-year longitudinal follow-up is scheduled.