Emergency reconstruction of extensor terminal slip defect by tendon plasty.

INTRODUCTION: We report our experience with a tendon plasty technique to reconstruct extensor terminal slip defect, with results in 11 patients. MATERIAL AND METHODS: The technique was proposed to 11 patients with mean tendon defects of 6 mm. Mean follow-up was 10.6 months. Clinical assessment comprised active distal interphalangeal (DIP) range of motion, active DIP extension and spontaneous DIP extension deficit. RESULTS: Mean range of motion was 50°. Active extension was restored in all cases. There was a mean 11° spontaneous DIP extension deficit. DISCUSSION: The present results confirmed those in the literature for this type of tendon plasty. As well as these encouraging outcomes, the technique has the advantage of being simple, with low morbidity thanks to remote harvesting.

Trapeziometacarpal osteoarthritis and arthritis of the wrist.

Although the simultaneous occurrence of arthritis of the wrist and the base of the thumb is rare, it is nonetheless imperative to carry out a preoperative clinical and radiological assessment of the wrist when managing trapeziometacarpal osteoarthritis. The presence of pre-arthritic lesions or established wrist arthritis, even if treated, must be taken into consideration when treating osteoarthritis at the base of the thumb. The coexistence of these lesions determines the entire surgical strategy. Failure to take them into account during the surgical treatment often results in a compromised postoperative course and it often adversely impacts the outcome of secondary surgeries.

Emergency metacarpophalangeal arthroplasty with bone grafting for traumatic joint destruction: a report on two cases.

Traumatic destruction of the metacarpophalangeal joints with bone defect is a technical challenge for surgeons when maintaining joint mobility is a priority for the patient. An emergency metacarpophalangeal arthroplasty with bone graft has been described in the literature for dorsal defects in the proximal phalanx. We have adapted this technique to allow us to perform this arthroplasty with bone graft in all defects of the proximal phalanx.

[Metacarpal shaft reconstruction using medial femoral condyle flap: A case report]. / Reconstruction diaphysaire métacarpienne par transfert osseux vascularisé de condyle fémoral interne : à propos d'un cas.

We report the technique applied to reconstruct a whole shaft defect of the 4th metacarpal bone in a 22-year-old women after aneurysmal bone cyst resection. Local invasion leads to possible poor revascularization possibilities, justifying the use of a vascularized bone transfer. Surgical procedure consisted in a 5-centimeter free medial femoral bone flap transfer. Two months after surgery, no after effect was found at donor site and bone consolidation was complete. Bone fixation allowed early active motion and a complete recovery of flexion-extension range was present 1 year after surgery. Free medial femoral condyle was described several times as a solution for metacarpal defects, in osseous or osteocutaneous versions, it represents a useful option in hand surgeons' armamentarium.

Epidemiology of traumatic upper limb amputations.

INTRODUCTION: While published data on functional outcomes after upper limb amputations are plentiful, epidemiology data are relatively rare. This led us to performing an epidemiology study of traumatic upper limb amputations at our facility. MATERIAL AND METHODS: This retrospective study spanned a 10-year period of cases seen at the SOS Main (Hand emergency center) of the Nancy University Hospital in France. Patients who suffered traumatic amputation of the upper limb were identified and divided into two groups: replantation and surgical amputation. All anatomical amputation levels were retained. Non-traumatic amputations were excluded. Epidemiology data (sex, age, dominant side, injured side) was collected along with the specific anatomical level of the injury, the injury mechanism and whether it was work-related. We also looked at the success rate of microsurgery and whether multi-finger amputations were partial or complete. In parallel, the annual incidence of amputations seen at the SOS Main over this period was calculated. RESULTS: Over the 10-year period, 1715 traumatic upper-limb amputations were identified, which was 3% of all cases seen at the SOS Main. Most of the cases involved middle-aged men. Revascularization was attempted in one-third of cases and microsurgery was successful in 70% of cases. The surgical amputation group consisted of 1132 patients with a mean age of 59 years, while the replantation group consisted of 583 patients with a mean age of 48 years. The primary mechanism of injury was a table saw. DISCUSSION: This injury, which must be addressed urgently, is not very common in everyday practice. This is contrary to lower limb amputations, which are more common and occur in the context of micro- and macroangiopathy in older patients. The success rate of microsurgery in this cohort must be placed in the context of age, amputation level and mechanism. The functional outcomes are not always as good as the vascular outcomes. This data is invaluable as it fills a gap in our knowledge about amputations. LEVEL OF EVIDENCE: IV.

Clinical and radiological outcomes following radioscapholunate fusion.

INTRODUCTION: Radioscapholunate (RSL) fusion is typically performed following wrist trauma. It addresses the pain caused by radiocarpal osteoarthritis but reduces the wrist's mobility. The objective of this study was to determine the long-term clinical and radiological outcomes of this procedure. MATERIALS AND METHODS: This was a retrospective study of all wrists operated for RSL fusion in our surgery unit over a 12-year period. The clinical analysis consisted of joint amplitudes, grip strength, pain (VAS) and functional scores (PRWE, QuickDash, Mayo Wrist Score). The radiological analysis focused on bone fusion and the presence of midcarpal osteoarthritis. RESULTS: This surgery procedure was performed on 48 wrists. Of these, 34 patients were available for review, including 6 who had subsequently undergone total wrist fusion after the RSL procedure. The average follow-up was 53 months. Flexion/extension and radioulnar deviation were 56° and 30°, respectively. Grip strength in the operated wrist was 71% of the contralateral wrist. The mean pain level was 3 out of 10. The PRWE, QuickDash and Mayo Wrist Score were 35.7, 44.5 and 57.2, respectively. Seventy-nine percent of patients were satisfied with the outcome. The fusion rate was 71%, the midcarpal osteoarthritis rate was 64% and the STT osteoarthritis rate was 46%. DISCUSSION: Reduced wrist range of motion in patients who have undergone RSL fusion helps to preserve satisfactory function in the majority of patients; however, the functional outcome scores point to some hindrance in day-to-day activities. Nonunion occurred in nearly one-quarter of patients and appears to be preventable by excision of the distal pole of the scaphoid (DPS). Midcarpal osteoarthritis develops in most wrists over the long-term and appears to be inevitable. CONCLUSION: RSL fusion is a palliative procedure that preserves some of the wrist's mobility. However, it is a difficult procedure that has a significant nonunion rate. Excision of the DPS may contribute to lowering the nonunion rate.

Emergency metacarpophalangeal arthroplasty with bone grafting for traumatic joint destruction.

Emergency arthroplasty of the metacarpophalangeal joint (MCPJ) remains a valuable treatment option in patients with MCPJ destruction but may raise challenges in the event of substantial metacarpal and/or phalangeal bone defects. We report three cases of MCPJ destruction with bone defects at the proximal first phalanx treated with emergency silicone implant arthroplasty combined with bone grafting.

Complete section of proper palmar digital pedicles: Correlation between arterial patency and sensory recovery.

Wounds to proper palmar digital (PPD) pedicles are frequent surgical emergencies. A correlation between arterial patency and nerve regeneration, however, has never been demonstrated. Forty-seven patients presenting complete section of a PPD pedicle and having undergone surgical repair of both elements were followed-up at a minimum of one year postoperatively. Doppler ultrasound examination studied arterial patency as well as the degree of stenosis. Neurological examination determined the BMRC score and the existence of cold intolerance, symptomatic neuroma and neurogenic pain. In 32 cases, the artery was permeable; in the remaining 15, arterial thrombosis was identified. In 14 out of the 32 permeable-artery subjects, stenosis had no significant effect; in the remaining 18 cases, circulation was reduced. BMRC scores showed 11 S4 cases, 16 S3+, 16 S3 and 4 S2. Twenty-nine cases of intolerance to cold were identified, along with two cases of neurogenic pain and 17 cases of symptomatic neuroma. A statistically significant correlation was shown between arterial patency and BMRC scores (Chi-square, P=0.0221) and neurological symptoms appeared to be linked to the degree of stenosis. Favorable BMRC scores were observed where the artery was permeable, notably where blood flow was not modified below the repair site. This observation also seemed valid regarding disabling neurogenic symptoms.

Intracarpal shortening osteotomy for Kienböck's disease: A retrospective study of 28 cases.

INTRODUCTION: Kienböck's disease is rare in patients with a neutral or positive ulnar variance. In these situations, treatment is challenging and controversial. Various intracarpal shortening osteotomy (ICSO) procedures have been proposed. OBJECTIVE: Study the effect of the type of ICSO (isolated capitate osteotomy or combined with hamate osteotomy) on the clinical and radiological outcomes in a retrospective series. METHODS: Patients with Kienböck's disease were treated with ICSO. A dorsal approach centered over the capitate was used. The transverse osteotomy was located 5mm below the capitate's proximal chondral boundary. The osteotomy cut was 2mm thick. In some patients, a hamate osteotomy was done at the same level as that of the capitate. The osteotomy site was fixed with staples. Cases were classified as with or without a vascularized bone graft was added to the ICSO. RESULTS: There were 28 cases and the average follow-up was 43 months. Three patients required surgical revision. Pain relief at rest was achieved in all patients. The flexion/extension range of motion was 84°. Strength was 75% of the opposite side. The mean QuickDASH was 32.5 and the PRWE (Patient Related Wrist Evaluation) was 30.2. Isolated capitate osteotomy resulted in better satisfaction and improved ulnar/radial deviation and flexion range of motion. There was no difference in terms of pain, strength and functional scores. However, it triggered a significant increase in the radioscaphoid angle. Adding a vascularized bone graft did not impact the outcomes. DISCUSSION: Isolated capitate osteotomy provides better outcomes than combined capitate/hamate osteotomy (satisfaction and wrist range of motion) and should be done as the primary procedure. However, since it increases the radioscaphoid angle more than combined capitate/hamate osteotomy, the latter procedure should be used when a large radioscaphoid angle exists preoperatively. We found no benefit of using a vascularized graft. LEVEL OF EVIDENCE: IV.

Lipofibromatous hamartoma of the radial nerve: An unusual location.

Lipofibromatous hamartoma is a congenital and ineradicable benign tumour of the peripheral nerve sheaths, affecting almost exclusively the median nerve and its branches. It corresponds to an infiltration of the nerve by lipofibramatous tissue that dissociates the fascicles. We report a highly unusual case of a lipofibromatous hamartoma of the radial nerve in the upper extremity in a 52-year-old female patient.

Minimum 10-year clinical and radiological follow-up of trapeziectomy with interposition or suspensionplasty for basal thumb arthritis.

HYPOTHESIS: The aim of this article is to analyze clinical and radiological outcomes of trapeziectomy performed for basal thumb arthritis after a minimum follow-up of 10 years to gain further insight from shorter and medium-term studies reporting satisfactory evolution. METHODS: We reviewed 67 trapeziectomies, operated on by the same senior surgeon after a minimum follow-up of 10 years. The sample included 16 cases of suspensionplasty and 51 interpositions. Clinical outcome evaluated strength, pain, joint amplitude, Kapandji opposition score, Disabilities of the Arm, Shoulder and Hand score, complications and revision surgery. Radiological evaluation criteria included osteoarthritis and collapse of the trapezial void. RESULTS: After a 10-year follow-up, clinical results remained stable despite radiological degradations. Long-term clinical outcomes of trapeziectomy for basal thumb arthritis are very positive, with interpositioning as an isolated procedure appearing, clinically, to be the preferred treatment despite greater radiological degradation when compared to suspensionplasty. CONCLUSION: In addition to offering insight into minimum 10-year follow-up, this study also pinpoints this paradoxical dissociation of clinical-radiological outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

An articular spacer for metacarpophalangeal fracture: The story of a crocodile bite.

Choosing the best option for reconstructing comminuted joint fractures in hand surgery raises technical challenges due to the small size of the anatomical structures and the required early mobilization. Single-stage reconstructions are clearly preferable, but when the infection risk is high, two-stage alternatives are needed. We report a case of fracture of the head of the 2nd metacarpal resulting from a crocodile bite treated by implanting an articular spacer.

Contaminated wounds: Effectiveness of debridement for reducing bacterial load.

Surgical management of contaminated hand wounds may seem anecdotal, but such injuries actually account for an appreciable amount of the activity in emergency hand centers, and recommendations put forward by scientific societies differ. Dealing effectively with this public health issue calls for clarifying the usefulness of the various available treatments. Our study's objective was to determine the effectiveness of surgical debridement. In this prospective study, 92 patients with contaminated hand wounds underwent surgical debridement. Selection criteria included the length of time between injury and treatment, and the mechanism of injury. Patients with infected wounds, those treated by antibiotics, who were immunosuppressed or had osteoarthritis were excluded. Skin samples were collected both before and after debridement. In 62% of cases, the wounds were contaminated before debridement. Following the procedure, 87% of the bacterial smears were negative. The comparison between debridement and smear results was statistically significant (Student's t test, P<0.001). Surgical debridement, with appropriate irrigation, can effectively eradicate bacterial flora due to contamination.

Bennett fracture: Arthroscopically assisted percutaneous screw fixation versus open surgery: Functional and radiological outcomes.

BACKGROUND: Arthroscopically assisted percutaneous screw fixation has been introduced to decrease the invasiveness of treatments for intra-articular fractures. HYPOTHESIS: Arthroscopically assisted percutaneous screw fixation of Bennett fracture simplifies the postoperative course compared to open surgery. MATERIAL AND METHODS: Twenty-one Bennett fractures detaching at least one-third of the joint surface were studied retrospectively. Among them, 11 were managed by percutaneous screw fixation and 10 by open surgery. Follow-up was at least 12 months. Clinical and radiological evaluations were performed to assess the development of complications, tourniquet time, immobilisation time, sick-leave time, QuickDASH score, Kapandji score, grip strength, pinch strength, return to work activities, intra-articular screw migration, inadequate reduction, non-union, and joint remodelling. RESULTS: The percutaneous group had significantly shorter immobilisation (P<0.0001) and tourniquet (P=0.0068) times. The number of complications was 1 in the percutaneous group and 6 in the open-surgery group. Whereas no adverse radiographic outcomes were found in the percutaneous group, the open-surgery group had 2 cases of inadequate reduction, 3 cases of joint remodelling, and 4 cases of intra-articular screw migration. The number of patients unable to return to their previous work activities was 1 (9%) in the percutaneous group and 3 (30%) in the open-surgery group. DISCUSSION: Arthroscopically assisted percutaneous screw fixation seems to ensure a simpler postoperative course, with fewer clinical and radiographic complications, as well as shorter tourniquet and immobilisation times. LEVEL OF EVIDENCE: IV, retrospective comparative study.

Locking plate fixation versus antegrade nailing of 3- and 4-part proximal humerus fractures in patients without osteoporosis. Comparative retrospective study of 63 cases.

INTRODUCTION: There is no consensus on the treatment of proximal humeral fractures. The goal of the present retrospective observational study was to compare functional and radiological results and complications of internal fixation using locking plates versus antegrade nailing in the treatment of non-osteoporotic Neer classification 3- and 4-part fractures after a least 1 year of follow-up. MATERIAL AND METHODS: Internal fixation was performed in 67 fractures (1 bilateral): 35 by locking plate (1 lost to follow-up, 1 deceased) and 32 by intramedullary nailing (2 lost to follow-up) between January 1st, 2004 and December 31st, 2010. Thus, the study included 33 plates (21 3-part and 12 4-part fractures) and 30 nails (21 3-part and nine 4-part fractures). Final functional assessment was based on the Oxford, Constant, Relative Constant and QuickDASH scores and percentage of handicap. Radiological follow-up included immediate postoperative, 6 weeks, 3 months and 1 year AP and Lamy lateral views. All complications were recorded prospectively. RESULTS: Mean Oxford, Constant, Relative Constant and QuickDASH scores and percentage of disability for the plate and nail groups respectively were: 23.8 vs. 23.3, 59.7 vs. 60 6, 73.5 vs 79.3, 20.9 vs 21.0, 22.6 vs 22.6. Multivariate analysis did not show any significant difference in functional scores or quality of reduction: final unsatisfactory reduction on AP view, 30.3 vs. 36.7%; lateral view, 3.2 vs. 10.0%; greater tuberosity, 9.1 vs. 16.7%. Four-part fracture (P<0.05), frontal reduction defect at follow-up (P<0.05) or greater tuberosity defect (P>0.05) had negative impacts on functional scores. The complication rates corresponded to those in the literature and did not differ between the techniques (P=0.1901) except for three infections in the plate group. DISCUSSION-CONCLUSION: Internal fixation is the treatment of choice for 3- and 4-part fractures in non-osteoporotic patients. Although no difference was found in the present study between locking plate and intramedullary nailing, the former seems to be less well adapted and more aggressive. TYPE OF STUDY: Retrospective observational study. LEVEL OF EVIDENCE: Level 4.