Serum carboxymethyllysine concentration is associated with erosive hand osteoarthritis.

OBJECTIVE: Carboxymethyllysine (CML) and homocitrulline (HCit) are the products of two non-enzymatic post-translational modifications of protein, a process related to age. We investigated whether serum CML and HCit concentrations were associated with hand osteoarthritis (HOA), especially erosive HOA. DESIGN: Serum CML and HCit were measured by using liquid chromatography coupled with tandem mass spectrometry at inclusion in 386 patients included in the DIGItal Cohort Design (DIGICOD) cohort. We investigated whether serum CML and/or HCit concentrations were associated with erosive HOA or with HOA clinical and radiological features. Moreover, we compared the tissular concentrations of CML and HCit in OA and non-OA cartilage from proximal interphalangeal and metacarpo-phalangeal (MCP) joints from human cadaveric donors. RESULTS: Median (IQR) serum CML concentration was lower in patients with erosive HOA than those with non-erosive HOA (178.7 [157.1-208.8] vs 194.7 [168.9-217.1] µmol/mol Lys, P = 0.002), but median HCit concentration did not differ between the groups (193.9 [162.9-232.0] vs 193.9 [155.9-224.6] µmol/mol Lys). Cartilage HCit and CML concentrations were not correlated with clinical features. Serum CML concentration was higher in OA than non-OA MCPs (7.0 vs 4.0 mmol/mol Lys, P = 0.01). CONCLUSIONS: Serum CML concentration was lower in erosive HOA than non-erosive HOA, and cartilage CML concentration was higher in OA than non-OA cartilage. These results encourage further studies to test whether serum CML could be a new prognostic biomarker in HOA.

Systematic use of short unicortical epiphyseal locking screws versus full-length unicortical locking screws in distal radius fracture volar plating: A prospective and comparative study.

PURPOSE: Volar locking plates, used in distal radius fracture (DRF), present a risk of injuring extensor tendons with screws penetrating the dorsal cortex of the radius. Actually, even when aiming to use maximum-length unicortical locking screws, some still could be bicortical. We hypothesize the use of only short unicortical screws would allow a proper stabilization of the radial epiphysis without the risk of dorsal cortex penetration. MATERIALS AND METHODS: A prospective monocentric non-randomized study was conducted. Patients with DRF (excepted for partial dorsal joint fractures) were treated in group A with short locking epiphyseal screws (16 mm for females, 18 mm for males) and in group B with full-length unicortical locking screws. Ultrasound was done 3 months postoperatively to evaluate the number and length of prominent dorsal screws. X-rays were performed after 6 weeks to assess stability according to volar tilt and radial inclination variations. RESULTS: There were 37 patients in group A and 39 in group B with 148 and 156 epiphyseal screws, respectively. In group A, there were 0% of dorsal penetrating screws against 6.5% (10 screws from 8 patients) in group B (p < 0.05). There was no significant difference for the stability between the groups: mean volar tilt variation ( - 0.6° vs. - 0.7°) and mean radial inclination variation ( - 0.4° vs. - 0.4°). CONCLUSION: For a same stability with volar locking plates for DRF, short epiphyseal locking screws should be preferred to full-length unicortical screws in order to prevent extensor tendon injuries. Based on 75% of distal radial average anteroposterior width for each sex, screw lengths of 16 mm for females and 18 mm for males seem to be the length to use. LEVEL OF EVIDENCE 2: Prospective, Comparisons made, non-randomized.

[The wrapping induced membrane technique for treating recalcitrant non unions]. / La technique de la membrane induite « engainante ¼ pour le traitement des pseudarthroses rebelles sans perte de substance osseuse et le renforcement des reconstructions osseuses segmentaires fragiles. Rapport préliminaire.

The induced membrane technique is now well accepted for reconstruction of segmental bone defect. On the other hand, some cases of aseptic non-union are unsuccessfully treated by several surgical attempts for obtaining bone healing. The two stages wrapping induced membrane technique was developed initially for treating atrophic and recalcitrant aseptic non union without bone loss. At the first stage, the site of non-union was firmly fixed and tiles of cement were placed close to the bone on two or three aspects of the bone. At the second stage, after removing the spacers, the induced cavities were filled with cancellous bone autograft. In the two reported cases bone healing was acquired in 4 months. One case was a recalcitrant atrophic non-union of the humeral shaft, the other case concerned the enhancement of an insufficient segmental reconstruction of the femur. The follow up were respectively 3 years and 2 years without complication. The membrane induced by the cement tiles prevents the bone graft resorption and improves the osteogenicity through its biological properties.

[The fascio-cutaneous fibular island flap]. / Le lambeau fasciocutané fibulaire en ilôt.

The perforators of the fibular artery provide a well vascularised supra fascial network which allows to raise a proximally or a distally based island fascio cutaneous flap with an adipo-fascial pedicle. We present a short series of five cases of this flap for coverage of soft tissue defects involving the region of the knee, the distal third of the leg and the lateral aspect of the heel. All flaps healed entirely without venous congestion. The advantages of the fascio cutaneous fibular island flap are the supine operative position, the preservation of the sural nerve and the lesser saphenous vein and a pivot point which can be located at the middle third of the leg. According to our experience, the fascio cutaneous fibular island flap is especially indicated for repairing defects of the distal leg.

Palliative surgery for thumb involvement in ulnar paralysis.

Ulnar paralysis has multiple clinical presentations, which are due to partial recovery or to anatomical variations between the ulnar and median nerves. The main sequelae of ulnar nerve paralysis are the loss of hand strength with impairment of all intrinsic functions of the fingers and some of the thumb's functions. Weakness of the adductor pollicis and flexor pollicis brevis muscles may manifest as weak key pinch with automatic flexion of the thumb interphalangeal joint when gripping. Indications for palliative surgery have decreased due to advances in peripheral nerve surgery. However, palliative surgery still has a significant role to play when nerve repair techniques are not indicated or do not provide satisfactory results. The principle is to reinforce metacarpophalangeal flexion while stabilizing the thumb's interphalangeal joint, thus supplementing the action of the flexor pollicis brevis. This is generally done by transferring the flexor digitorum superficialis tendon of the fourth finger to the distal insertion of the superficial thenar muscles and the extensor pollicis longus. Restoration of the first dorsal interosseous is more rarely indicated.

Tendon transfers to restore elbow flexion.

Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable.

Treatment of congenital syndactyly.

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Chondrodesis of the wrist in children with severe paralytic hand deformities.

We examined the anatomical and clinical results of a new wrist subphyseal arthrodesis method called chondrodesis, which relies on resorbable suture-bone fixation for children with severe paralytic hand deformities and does not require fixation devices or bone grafting. Four children's wrists underwent the procedure, resulting in three successful wrist bone fusions. The wrists were stabilized by joint fusion in 4-5 months in good positions, ranging from neutral to extension 15°, while still allowing the forearm to keep growing since the radial growth plate remained open as of the last follow-up. The procedure improved hand function (House score, Raimondi score) and appearance. It also increased control over gripping motions with the operated hand, and even restored key pinch ability in one of the patients. The youngest patient was not able to achieve bone fusion at the key sites and will need further corrective procedures at a later and more optimal age. This novel procedure is appealing because of its technical reproducibility, low cost, encouraging outcomes, ease of rehabilitation, and because it spares the physeal cartilage.

Surgical strategy in extensive proximal brachial plexus palsies.

PURPOSE: To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI). METHODS: Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension. RESULTS: Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%). CONCLUSIONS: A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Transfer of the triceps brachii to the finger and thumb extensors: Anatomical study and report on one case.

Our aims were to study the anatomical feasibility of triceps brachii long head (TBLH) transfer to the extensor digitorum communis (EDC) and extensor pollicis longus (EPL) tendons through a medial route, and to report on its first clinical application. Dissections were conducted on 10 fresh-frozen cadaver specimens. Using a posteromedial approach, the TBLH was separated from the remaining triceps and extended distally with a fascia lata strip. This strip was then tunneled through a medial route and secured distally to the EDC and EPL tendons. The transfer tenodesis effect during elbow extension was assessed with metacarpophalangeal (MCP) joint motion of the thumb and index finger, and the distance between the thumb and index finger tips (TI distance). This transfer was performed in an eight-year-old boy with incomplete recovery of a right brachial plexus birth palsy; preoperatively, shoulder and elbow functions were recovered as well as active gripping distally, but he had no active wrist or finger extension. With the trapeziometacarpal and radiocarpal joints stabilized, 90° elbow extension provided a mean extension of the thumb and index finger MCP joints of 34 ± 5° and 90 ± 11°, respectively, with a mean TI distance of 116 ± 16 mm. Twelve months after surgery, the boy had full active MCP joint extension, independent from elbow extension. Transferring the TBLH to the EDC and EPL tendons is anatomically feasible. Larger clinical studies will be needed to assess more adequately its functional outcomes.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases.

PURPOSE: The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. METHODS: We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. RESULTS: At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DISCUSSION: A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. LEVEL OF EVIDENCE: Level IV.