Tendon transfer surgery for radial nerve palsy.

Palliative tendon transfer is an integral part of radial nerve palsy treatment. It can be considered in the first weeks when the possibility of nerve repair by direct suture or nerve grafting is not feasible or reasonable. Mostly, it is discussed secondarily when it is too late for nerve surgery and motor recovery cannot be expected, or after failure or incomplete recovery after nerve repair. The goal of tendon transfers is to restore wrist, finger and thumb extension. For wrist extension, the use of pronator teres is well accepted. The best tendon transfer for finger extension is debated. This can be restored doing a flexor carpi ulnaris (FCU), flexor carpi radialis or flexor digitorum superficialis (FDS) to extensor digitorum communis transfer. Regarding thumb extension and abduction, a palmaris longus (PL) or one FDS tendon to the rerouted extensor pollicis longus (EPL) transfer can be performed. If a transfer is done on the EPL without rerouting it, abduction can be restored by doing a tendon transfer to the abductor pollicis longus (APL) or an APL tenodesis. The different tendon transfer options are selected based on the surgeon's preference, and most importantly, discussed with the patients to define the objectives together. The transfer is chosen based on the clinical examination (high or low radial nerve palsy, tendon available for transfer like PL, wrist mobility) and based on the patient's needs and expectations (activities requiring the FCU, finger independence, independence of thumb extension or abduction). If the surgical rules and the postoperative instructions for rehabilitation are followed, tendon transfers for radial nerve palsy regularly produce very satisfactory results.

Early postoperative dressing removal in hand surgery: Novel concepts for individualized surgical dressing management.

Postoperative dressing protocols after clean surgery without implant vary widely. The purpose of this study was to elucidate whether early postoperative dressing removal is a valid option, as compared to untouched dressing or twice-weekly dressing change approach. A prospective randomized study was conducted on patients who underwent carpal tunnel release (CTR) or trigger finger release (TFR) between January and November 2020. Patients were randomly distributed into 3 groups: surgical dressing untouched until first follow up (SDU); surgical dressing changed twice a week in a health maintenance organization (HMO); and surgical dressing removed at first postoperative day (SDR). Data collected included patient characteristics, pre-and post-operative functional (QuickDASH) and autonomy (Instrumental Activities of Daily Living performance (IADL)) scores, Vancouver scar scale (VSS) and potential complications. Eighty-four patients were included: 28 (33.3%), 29 (34.5%) and 27 (32.1%) in the SDU, HMO and SDR groups, respectively. Deterioration in mean IADL score at 2-week follow-up was statistically significant in the HMO group (mean delta 3.35, p = 0.008). Quick DASH score improved significantly between preoperative and 2-week follow-up values only in the SDU group (mean delta 9.12, p = 0.012). Other parameters, including wound complications, did not differ significantly between groups. Early removal of postoperative dressing and immediate wound exposure was a safe option after CTR and TFR. An untouched bulky dressing correlated with early functional improvement. Finally, iterative dressing change in HMO showed no benefit and led to significant deterioration in early postoperative autonomy. IRB APPROVAL: 0548-18-TLV. LEVEL OF EVIDENCE: I.

Two-stage extensor tendon graft using the Paneva-Holevitch procedure: A new technique.

Reconstruction of the extensor tendons remains a therapeutic challenge. Tendon transfers and grafts are a potential source of morbidity at the donor site, and the graft stock is limited. In the index finger, the tendon of the extensor indicis proprius can be anastomosed to the tendon of the extensor digitorum, and then the extensor digitorum tendon turned over after being cut at the forearm. We assessed the feasibility of this reconstruction on 12 upper limbs from 6 cadavers and we report the case of a 24-year-old patient who suffered destruction of the extensor apparatus in the index and middle fingers. For the cadaver study, in each case, the tendon could be moved onto the proximal interphalangeal joint, after having done an anastomosis downstream of the extensor retinaculum. The mean graft length was 13cm (9.7-15.2). This method was used in one clinical case with an excellent outcome. This is a simple technique that is without consequences since the tendons used are already cut, therefore saving a tendon graft. This technique should be part of our therapeutic arsenal.

Accessory extensor pollicis longus: A rare tendon anomaly.

This report provides a complete review of a rare anatomical variation, the accessory extensor pollicis longus (EPL) tendon and its clinical significance. We will describe a case of an asymptomatic accessory EPL that was found incidentally during surgery with a tendon located in the fourth extensor compartment. Pulling on it induced extension of the thumb interphalangeal joint. Very few cases of accessory EPL have been previously reported with various muscle origins and tendon insertions. In the literature, three symptomatic cases of accessory EPL were reported with a tendon running in a compartment other than the fourth. Although this variation is asymptomatic in most cases, knowledge of its existence might be useful in routine procedures to avoid inadvertent tendon damage, or during tendon repair.

[Nerve injuries associated with distal radius fractures]. / Lésions nerveuses associées aux fractures de l'extrémité distale du radius.

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.

Mid-term results of arthroscopic Bankart repair: A review of 31 cases.

INTRODUCTION: The goal of this study was to assess the overall function (Walch-Duplay score), stability, time and because it is time of return to sport and level of return to sport, and satisfaction of patients who underwent an arthroscopic Bankart repair for chronic anterior shoulder instability at 5 years' follow-up. In addition, the potential correlation between the postoperative Walch-Duplay score and the presence of risk factors for recurrence, the ISIS score, associated labral lesions discovered intraoperatively and clinical presentation was determined. MATERIAL AND METHODS: This was a retrospective, single-centre study of 30 patients (31 arthroscopic Bankart procedures) operated between January 2003 and December 2012. The Walch-Duplay score, recurrence rate (dislocation or subluxation), return to sports and subjective satisfaction were evaluated. RESULTS: The mean postoperative Duplay score was 77.4 points (100-15)±30.6. At review, 25.8% of patients had recurrence of the preoperative symptoms, including 16.1% glenohumeral dislocation and 9.7% subluxation. Patients requiring revision surgery (Bristow-Latarjet procedure) had no additional instability episodes. Among the athletes, 16 (66.6%) returned to their pre-injury level, four (16.6%) changed to a different sport and four stopped participating (16.6%). The subjective evaluation of the procedure was satisfactory in 75% of cases. No risk factors for recurrence were significantly related to the Walch-Duplay score. CONCLUSION: Despite satisfactory Walch-Duplay scores and subjective results, this mid-term follow-up study revealed a significant number of patients with recurrent instability after arthroscopic Bankart repair, confirming published data. Careful patient selection is essential prior to proposing this procedure and patients should be informed of the potential risk of revision surgery. LEVEL OF EVIDENCE: Level IV, retrospective study.

Antipsychotic effects of bretazenil, a partial benzodiazepine agonist in acute schizophrenia--a study group report.

The results of an open tolerability and exploratory efficacy study of bretazenil, a partial benzodiazepine-receptor agonist in hospitalized schizophrenic patients with an acute psychotic episode (DSM-III-R criteria), are presented. The duration of the study was 6 weeks, with a mandatory titration (ascending doses of 3-18 mg/day) period of 14 days. The assessment criteria for tolerability were the frequency of adverse events (including EPS), vital signs and laboratory tests. The efficacy criteria, which were only descriptively analysed, were: (a) Clinical Global Impression (CGI, percentage of "very much" and "much" improvement); and (b) change in BPRS total score (e.g. percentage of patients showing > or = 40% decrease of BPRS score at the end of the treatment). Sixty-six patients (aged 21-62 years) with acute episodes of schizophrenia of moderate to marked severity (mean BPRS score = 46.3, range 26-76) were included in the study. Of these 66 patients (68%) were reportedly non-responders (n = 10) or partial responders (n = 35) to previous neuroleptic therapy. Twenty patients (30%) terminated the trial prematurely due to therapeutic failure (no improvement or worsening after 2 weeks of treatment), 17% of patients dropped out due to other reasons (transfer to other hospitals, withdrawal of consent, intercurrent diseases) and 4.5% of patients stopped the treatment due to adverse reactions. Four patients (6%) showed early complete remission and refused to be further treated. The analysis of efficacy (intention-to-treat) revealed a sustained decrease of BPRS scores with 49% of patients showing > or = 40% BPRS score change by the end of the treatment. Forty-four per cent of patients improved "very much" or "much". Eleven patients (17%) were full responders (BPRS score decrease 75-100%) and 21 patients (32%) showed at least 40% reduction of BPRS score. The reduction of BPRS scores in completers only was 60%. All BPRS factor scores decreased in parallel and, particularly, no preferential decrease of anxiety/depression subscores was found. The analysis of tolerability showed that 59% of patients presented no complaints at all. The most frequent treatment-related adverse reactions in the remaining patients were: sedation (n = 14), dizziness (n = 4) and headache (n = 3). The results of this study suggest moderate antipsychotic efficacy of bretazenil in schizophrenic patients. They encourage further investigations of partial benzodiazepine-receptor agonists in this indication, particularly because of the excellent tolerability and lack of extrapyramidal side-effects.

Benzodiazepines and GABA hypothesis of schizophrenia.

Clinical and experimental studies pertinent for demonstrating the antipsychotic potential of benzodiazepines (BDZ) and the involvement of γ-aminobutyric acid (GABA) in the origin of schizophrenia are reviewed. It is shown that, due to severe methodological problems and pitfalls, placebo-controlled, double-blind studies do not permit unequivocal conclusions on the efficacy of BDZs, but neither do they completely disprove it. Furthermore, at first glance, confusing and controversial findings in animal models indicate a bi-directionality of effects of full BDZ agonists on dopamine-mediated functions, which may perhaps be explained by (i) anatomical and functional organization of the GABA-dopamine system in the nigro-striatal and ventro tegmental area, and (ii) the regional non-selectivity of action of these drugs. The recent demonstration of structural polymorphism of the GABA(A)-BDZ receptor complex and heterogeneous distribution of sets of subunits of the GABA( A)-BDZ receptor in the brain, suggests possibilities for development of partial BDZ agonists showing greater regional selectivity of action and thus potentially more specific antipsychotic action. Initial clinical results with bretazenil (Ro 16-6028), a partial BDZ agonist, in acute schizophrenia are, in this respect, an encouraging lead to be followed further.