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.

[Tenosynovectomy of the flexors in rheumatoid polyarthritis. Analytic study of short term and long term mobility of the fingers]. / Ténosynovectomie des fléchisseurs dans la polyarthrite rhumatoïde. Etude analytique à court et à long terme de la mobilité des chaînes digitales.

Between 1970 and 1988, 115 patients with rheumatoid arthritis underwent flexor tenosynovectomy. Fifty patients were reviewed (64 hands). The diagnosis of flexor tenosynovitis remains a clinical diagnosis. Three main groups can be distinguished: isolated carpal tenosynovitis (20%), palmodigital tenosynovitis (50%), diffuse tenosynovitis (30%). Standard surgical techniques were used, particularly in terms of the incisions. All patients underwent rehabilitation in the same rehabilitation centre. The authors analyse their results by comparing overall preoperative and postoperative mobility of the fingers (TAM: Total Active Motion, TPM: Total Passive Motion) and the angular gain in each joint (MCP, PIP, DIP). They report the results obtained at 4 months to eliminate the bias related to progression of the disease. The long-term results (8 years of follow-up) are also analysed. Statistical analysis compares two groups depending on whether flexor tenosynovectomy was isolated (44%) or combined with a dorsal surgical procedure at the same operation (extensor synovectomy, articular synovectomy, stabilisation-realignment of the dorsal aspect of the wrist, resection of the ulnar head) (56%). Ninety percent of patients declared themselves to be subjectively improved. Objectively, mobility was always improved at 4 months then deteriorated to return to its preoperative level at 8 years. Only three patients were reoperated for recurrence. Flexor tenosynovectomy in rheumatoid arthritis is an excellent operation. Its analgesic effect is maintained in time and, when performed early, it appears to protect the patient from the risk of subsequent tendon rupture.

["Desensitization" technique in the rehabilitation of the painful hand]. / Techniques de "désensitization" dans la rééducation de la main douloureuse.

Hand injury patients fairly frequently develop, soon after the injury, hypersensitivity phenomena on contact of the hand with the environment, which may lead to exclusion of the hand. The authors attempt to explain this syndrome on the basis of the pathophysiological theories concerning pain. American authors have proposed an original desensitization treatment based on simple and varied techniques, which provides extremely encouraging results.

[Radio-carpal amputation and prosthesis]. / Amputation radio-carpienne et appareillage.

Radio-carpal amputation was rejected for a long time because of the difficulties of fitting both myoelectrical and mechanical prostheses, only allowing a purely aesthetic prosthesis. As a result of miniaturization of control systems and the progress in computers, we believe that this now constitutes the best site for amputation whenever it is possible. Preservation of the antero-posterior bony contours of the radius allows the use of short sockets attached by a system of clips. In this way, flexion-extension of the elbow is left free and the movements of pronation and supination can be used. Liberation of the proximal joints facilitates integration of the prosthetic hand.

Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis.

OBJECTIVE: To evaluate the influence of methotrexate (MTX) on the frequency of postoperative complications in patients with rheumatoid arthritis (RA). METHODS: We conducted a randomized unblinded prospective study in 64 patients with RA treated with MTX and who underwent orthopedic surgery. Two groups of patients were constituted: in Group A (32 patients), MTX was interrupted 7 days before the surgery; in Group B (32 patients), MTX was not discontinued. RESULTS: Fifty surgical procedures were performed in Group A and 39 procedures in Group B. No postoperative infection was observed in any group. A prolonged wound healing was noticed in 6 cases in Group A and in 4 cases in Group B (not significant). CONCLUSION: We suggest that the interruption of MTX is not required in patients with RA when an orthopedic surgical treatment is planned. However a large prospective study is needed to make a definitive conclusion.