Pyrocarbon interposition implant after lunate resection in Kienböck's disease: A case series.

In advanced stages of Kienböck's disease, the lunate is no longer conservable. One of the surgical options is to resect the lunate and replace it with a prosthesis. The procedure consisted in lunate resection and interposition of a free APSI® or Pi2® pyrocarbon implant through a dorsal approach. Follow-up was clinical and radiological on QuickDASH and PRWE scores. At a median follow-up of 3 years, 12 patients were reviewed, with a median age of 56 years. Flexion significantly decreased from 42° to 28° (p < 0.01). Extension and pronation-supination were conserved. Strength was 94% compared to the opposite side, with no significant difference from the preoperative measurement. Median QuickDASH and PRWE scores were 15.9 and 23.5 respectively and had significantly improved. One patient underwent scaphocapitate fusion because she was still in pain; the other patients were pain-free. No patients had to change jobs because of their wrist. Radiographically, there was no carpal collapse and carpal height was conserved. Radioscaphoid angle and ulnar translation were stable. There was 1 case of asymptomatic implant dislocation. Interposition of a pyrocarbon implant after lunate resection in advanced Kienböck's disease is a motion-conserving procedure that provides pain relief and functional recovery in the short and medium term. LEVEL OF EVIDENCE: IV.

Restoration of thumb opposition (opponensplasty).

The authors review the therapeutic principles that must be applied when restoring the thumb opposition surgically. Among the many surgical techniques, five are featured: transfer of the flexor digitorum superficialis of the third or fourth finger, transfer of the extensor indicis proprius, transfer of the palmaris longus, translocation of the flexor palmaris longus tendon, transfer of the extensor pollicis longus. After summarizing the procedures, they emphasize the practical points that must be respected. This surgery, which cannot restore sensitivity, requires a precise assessment of the patient's wishes and information on what can be really expected.

Pyrocardan® implant after failed trapeziectomy.

The aim of this retrospective study was to analyze the medium-term results of patients treated with a pyrocarbon interposition implant (Pyrocardan®, Wright Medical™) after failed trapeziectomy. Eight female patients with an average age of 63 years were included in this single-center study. The average follow-up was 54 months (28-85 months). The average time elapsed between the trapeziectomy and the revision surgery was 116 months. Trapeziectomy failures were due to a painful scaphometacarpal and/or metacarpotrapezoid impingement. Patients were assessed radiologically and clinically for range of motion, strength (pinch and grip), pain (visual analog scale - VAS) and function (QuickDASH and PRWE scores). We found pain reduction with the mean VAS decreasing from 6.3 preoperatively to 2.5 postoperatively. Function improved with the QuickDASH and PRWE scores going from 52.9 and 49.1 preoperatively to 30.7 and 31.0 at the last follow-up, respectively. Strength and range of motion did not change significantly. Seven patients were satisfied or very satisfied with the surgery, while one patient did not experience any improvement after surgery. There was no radiological evidence of dislocation or bone reaction around the implant. Revision of failed trapeziectomy with the Pyrocardan® implant in cases of severe and painful first metacarpal subsidence is an effective solution that improves pain and function in the medium term.

Results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist at a mean 5 years' follow-up.

Management of severe joint involvement in rheumatoid wrist is controversial. The gold-standard is total wrist fusion, but total wrist replacement offers a motion-conserving alternative. The purpose of this study was to present the results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist. We performed a retrospective review of 28 arthroplasties for rheumatoid wrist arthritis. Eighteen females and 5 males were included, with a mean age of 55.7 years. Mean follow-up was 64 months. We measured range of motion, grip strength, and pain (on VAS). Function was evaluated preoperatively and at last follow-up with the DASH and PRWE scores. Mean range of motion in flexion-extension was maintained while mean inclination and rotational range of motion showed significant improvement. Mean grip strength increased from 10 kg to 17 kg. Mean pain score decreased from 6/10 to 2/10. Mean PRWE and QuickDASH scores decreased from 62/100 to 25/100 and from 62/100 to 36/100, respectively. Three patients underwent early reoperation to reposition a dislocated implant. No implants had to be removed. Amandys® pyrocarbon arthroplasty is a reliable alternative to total fusion or total replacement in rheumatoid wrist. Indications must be limited to well-aligned wrists with competent capsule-ligament structures.

Pyrocardan® implant arthroplasty for trapeziometacarpal osteoarthritis with a minimum follow-up of 5 years.

Many surgical procedures are available for treating trapeziometacarpal (TMC) osteoarthritis (OA). The aim of this study was to analyze the mid- to long-term outcomes of 103 pyrocarbon interposition arthroplasties in the TMC joint with Pyrocardan® implant performed prospectively in a single center to treat painful early stage OA. There were 96 patients with a median age of 59 years. Twenty-eight percent of patients were manual workers and 39% had a fixed dislocation of the first metacarpal. Fifteen percent of patients were 50 years old or more. After a minimum follow-up of 5 years, there was a marked improvement in the pain level (0.6/10), QuickDASH (9/100) and PRWHE (4/100) scores and strength (key pinch 8kg, grip strength 27kg). There were no differences in strength or range of motion compared to the opposite side. Four patients underwent revision surgeries. Two of them were converted to trapeziectomy. The 5-year implant survival rate was 96.2%. Dislocation of the first metacarpal was completely corrected in 80% of cases. Younger patients (≤50 years old) had slightly better outcomes than older ones. Overall satisfaction rate was 96%. Pyrocardan® interposition implant arthroplasty is a reliable alternative to trapeziectomy, total arthroplasty or fusion of the TMC joint especially for young, active patients.

Evaluation of a shape memory staple (Qual®) in radial shortening osteotomy in Kienböck's disease: A retrospective study of 30 cases.

The QUAL® (Memometal, Stryker) device is a shape memory staple used for bone fixation during distal radius shortening osteotomy in the context of Kienböck's disease. The present study is a retrospective, single-center and multisurgeon study of 30 patients with a mean follow-up of 8 years. Clinical criteria (range of motion (ROM), strength, pain and functional score) and radiographic data (ulnar variance, distal radius articular surface inclination, Lichtman stage, carpal height and bone healing) were evaluated pre- and post-operatively. We found satisfactory results with the mean grip strength of 22 kg/F before surgery and 24 kg/F after surgery. The mean ROM was 88° preoperatively and 82° postoperatively and the mean ulnar deviation was 23° preoperatively and 21° post-operatively. There was no change in radial deviation and pronation-supination after surgery. The average ulnar variance was 1 mm before surgery and 0.2 mm after surgery. The inclination of the distal radius articular surface on lateral and anteroposterior views and the mean carpal height were similar to the pre-operative ones. There was no delay in bone healing. The mean pain score was 2 at rest on a visual analogue scale after surgery. Seven patients experienced an increase in their Lichtman stage at the follow-up, and two patients were waiting for conversion to a non-conservative surgical treatment. Seven staples were removed postoperatively. Seventy-eight percent of patients returned to work after 3 months on average. Seventy-five percent of patients were at least satisfied with the outcome of their surgery. The QUAL® staple is a reliable option for fixation during shortening osteotomy of the radius in Kienböck's disease.

Arthroplasty of the proximal interphalangeal joint with the Tactys® modular prosthesis: Results in case of index finger and clinodactyly.

There are various surgical solutions for arthrosis of the proximal interphalangeal (PIP) joint: arthrodesis or denervation. Clinodactyly that is major and the index fingers are traditional contraindications for PIP arthroplasty prostheses. The recurrence of clinodactyly with ligament imbalance and mechanical complications are known complications. The purpose of our study was to evaluate the objective and subjective clinical results and radiological complications of Tactys® prostheses on the PIP joint of the index fingers or with clinodactyly of more than 5° in the other fingers. Two surgeons have implanted 35 total gliding modular Tactys® prostheses in 29 women and 3 men since 2010. The indications for surgery were arthrotic and painful PIP joints. Average pre-op clinodactyly was 7.03° (5-30°) with ulnar deviation (29 cases). Eleven index fingers presented with average clinodactyly of 14.2° (10-20°). The digits operated on were as follows: 13 index fingers, 14 middle fingers, 5 ring fingers and 3 little fingers. Arthrosis was primitive in 23 cases, post-traumatic in 6 cases and rheumatoid in 6 cases. The average age of patients undergoing surgery was 63.7 years (40-85). Objective (mobility, strength, index finger exclusion, scores, clinodactyly) and subjective (patient satisfaction, pain) functional results were collected by a neutral and independent observer, as were radiological complications. With an average follow-up of 2.6 years (1-6.3), the range of motion in all digits improved by 5.4° on average (55.5-60.8). The improvement in range of motion in the index fingers was 4.5° (57-61.5). Clinodactyly in all fingers was corrected by 1.36° (0-20). In the index fingers, average clinodactyly was 1.3° (0-10). The pinch strength in all PIP joints improved significantly from 2.3 kg (0.5-5) to 3.7 kg (1-8). On the PIP of the index fingers, the pinch strength had increased significantly from 2.5 kg (1-4) before surgery to 3.8 kg (1-7.5) post-op. Functional scores improved: PRWE (from 55.36 to 26.7/100), Quick DASH (from 54.6 to 30.5/100). Patient satisfaction was excellent in 15 cases, good in 8 cases, average in 10 cases, poor in 2 cases. The average VAS Pain Score improved from 5.6 to 1.45. We found 3 major complications requiring surgery: 2 stiffening and 1 mechanical loosening with secondary arthrodesis. Five patients presented with non-troublesome, reducible swan neck deformity and one algodystrophy. A gliding, fixed Tactys® prosthesis allowed us to restore ligament balance and to optimally rebalance the periarticular structures. The improvement in range of motion and the correction of clinodactyly was maintained over time. Total arthroplasty of the PIP with a Tactys® is no longer a formal contraindication for the index fingers and in cases of clinodactyly of more than 5°.

Adaptive Proximal Scaphoid Implant (APSI): 10-year outcomes in patients with SNAC wrists.

Radioscaphoid arthroplasty with the Adaptive Proximal Scaphoid Implant (APSI®) is an attractive treatment alternative in the short and medium term for patients with early scaphoid non-union advanced collapse (SNAC) wrist. The purpose of our study was to determine the long-term outcomes of this implant in SNAC wrists. All patients who received the implant from October 2002 to October 2010 were included. A clinical and radiographic study was performed. Our case series included 39 patients, of which 33 were contacted, with a mean follow-up of 10 years (5.8-13.4). Most of the patients had stage-1 SNAC wrist (95%). There were nine complications (27%), seven of which required reoperation: implant dislocation (44%) or progression of the carpal degeneration (33%). Ninety-six percent of patients contacted were satisfied or very satisfied with their surgery (although 21% needed a second surgery) with a Mayo Wrist Score of 80/100 and a Patient-Rated Wrist Evaluation of 17.5/100. Wrist strength was 86% of the contralateral side. Flexion-extension range was 101° and pain assessed using a visual analog scale was at 1.2 (0-6). We report satisfactory and lasting results with the APSI®, similar to those of scaphoid excision with four-corner fusion and proximal row carpectomy. Hence, the APSI® is a reliable alternative for treating osteoarthritis in SNAC wrists.

Treatment of scaphotrapeziotrapezoid osteoarthritis with the Pyrocardan® implant: Results with a minimum follow-up of 2 years.

The aim of this study was to report the results of arthroplasty using a mobile pyrocarbon implant (Pyrocardan®) for isolated scaphotrapeziotrapezoid (STT) osteoarthritis. The hypothesis was that this arthroplasty leads to functional improvement without carpal instability. Twenty patients (22 implants) were included with a minimum follow-up of 2 years and an average age of 59.6 years. Outcome criteria were pain (VAS scale), QuickDASH and PRWE scores, strength (grip and pinch), wrist mobility, the Kapandji index, carpal height and the capitolunar angle measured on X-rays. The preoperative data was compared to the postoperative data. The average follow-up was 3.8 years. There was a significant improvement in pain, clinical scores and pinch strength. In terms of range of motion, we found that amplitudes were maintained except for a significant decrease in wrist extension. X-rays did not show any carpal instability; carpal height was maintained and the capitolunar angle was significantly improved. No implant dislocation was reported. The good functional and radiographic outcomes, and the absence of surgical complications are evidence that the Pyrocardan® resurfacing implant is a valid option for treating STT osteoarthritis. If this arthroplasty procedure fails, another procedure can still be done. However, a long-term assessment of this technique is still needed.

[Dorsal cutaneous adipofascial flaps of long fingers]. / Les lambeaux cutanés a pédicule adipofascial de la face dorsale des doigts longs.

We report a series with the adipofascio cutaneous flap of the dorsal aspect of long fingers used with an anterograde or retrograde pedicle. Thirty flaps were performed in 29 patients with a mean age of 43 years, 16 cases in emergency and 13 cases secondary for the treatement of traumatic sequelae. The adipofascial pedicle was retrograde for 22 flaps and anterograde for 8 flaps. The donor site was adjacent of the cutaneous defect in 21 cases or at a distance in 9 cases. Transcient veinous congestion was observed in 2 cases. No necrosis was reported. A second surgery of plasty was performed in 1 case for a cutaneous bulk. The quality of the cutaneous coverage gave any functional discomfort and was evaluated very satisfying. These flaps have an important adaptabily of utilization depending on the localisation and the size of the cutaneous defect as well as the quality of its surrounding skin. The homodigital feature of these flaps avoids the disadvantages of the dorsal hand flaps or the heterodigital flaps. Due to their anastomotic vascularisation, these flaps are reliable and therefore can be recommended for the treatment of dorsal cutaneous defects of long fingers less than 2.5 cm.

Arthroplasty of the proximal interphalangeal joint with the TACTYS® prosthesis: Preliminary results after a minimum follow-up of 2 years.

The TACTYS® implant is a new anatomic gliding articular and modular prosthesis for the proximal interphalangeal (PIP) joint. We report preliminary results with a minimum follow-up of 2 years. Twenty-two patients with a mean age of 63 years were operated on at a single center by two senior hand surgeons. Indications were painful and stiff PIP joints. The joint damage was caused by osteoarthritis (18 cases), post-traumatic arthritis (3) and rheumatoid arthritis (1). All prostheses were implanted through a dorsal mid-line transtendinous approach. Postoperative active and passive range of motion in flexion and extension was performed immediately with a protective splint for 2weeks. All patients were evaluated (pain, range of motion, strength, function, X-rays) with a mean follow-up of 34months (range 24-50). Pain decreased from 6.5 preoperatively to 1.9 postoperatively on a VAS scale. Flexion-extension range of motion increased from 39° preoperatively to 58° postoperatively. Grip strength was 21kg preoperatively and 25kg postoperatively. Pinch strength was 3kg preoperatively and 5kg postoperatively. Functional QuickDASH and PRWE scores were significantly improved at the last follow-up. Four patients were reoperated on: dorsal tenoarthrolysis in 3 cases and volar osteophyte removal in 1 case. All implants were still in place at the last follow-up. On X-rays, there were no signs of implant migration or loosening. The modularity of the prosthesis seems to be this implant's greatest advantage. The TACTYS® prosthesis is a reliable alternative to other conventional PIP implants.

Retrospective study of two fixation methods for 4-corner fusion: Shape-memory staple vs. dorsal circular plate.

The purpose of this study was to compare the results of two groups of patients with four-corner fusion, one group fixed with shape-memory staples and the other with locked circular plates. This retrospective study compared 52 wrists operated for scaphoid excision and four-corner fusion between 2005 and 2011. The arthrodesis was ensured by a shape-memory quadripodal staple (4Fusion(®), Memometal™) in 37 cases and a locking dorsal circular plate (Xpode(®), Biotech Ortho™) in 15 cases. In the staple group, the mean age was 58.5 years and the average follow-up was 4.3 years. In the circular plate group, the mean age was 58.6 years and the average follow-up was 3.1 years. Pain, range of motion, grip strength, functional scores (QuickDASH and PWRE), fusion of the midcarpal joint, complications (implant fracture and reoperation) and patients' satisfaction were used as outcome measures. There was no pain in 43% of patients in the staple group and 40% of patients in the circular plate group at the follow-up; range of motion and functional scores were similar in both groups. Seventy-five percent of patients in the staple group were satisfied or very satisfied versus 60% in the circular plate group. The implant broke in 24.3% of cases in the staple group and 60% in the circular plate group. Reoperation was needed in 18% of the staple cases and 14% of the plate cases. There was no difference between the implants in terms of pain, range of motion, functional scores and patient satisfactory. The implant fracture rate in the plate group was high. This study brings into question implant reliability for the four-corner fusion procedure.

Return-to-work interval and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients.

AIM OF THE STUDY: To evaluate the connection between the type of patient insurance and the time taken to return to work after carpal tunnel surgery. PATIENTS AND METHODS: Two hundred and thirty-three patients in full-time work were operated on for carpal tunnel syndrome between 1 January and 30 June 1998. They were divided into three groups: independent workers (n=87), wage earners in the private sector (n=90) and civil servants (n=56). Four categories were defined: manual workers, non-manual workers, patients with social security insurance and patients with workers compensation. The average return-to-work interval after surgery for each of the groups was evaluated and compared group by group. RESULTS: For independent workers the average time off work is 17 days, for those in the private sector it is 35 days, and for civil servants it is 56 days. Patients with social security insurance were off work for 32 days and those with workers compensation for 49 days. DISCUSSION: The comparison shows significant differences with regard to social security insurance: the return-to-work interval in civil servants is larger than for private sector workers, and this is higher than in independent workers. The difference between patients with workers compensation and those with social security insurance is 17 days and significant. There is a significant difference between manual and non-manual workers in independent and private sector workers. There is no significant difference between the sub-groups in the civil servants. These cross references enable us to work out the influence that social security status has on the return-to-work time following surgery.

[Surgical treatment of lymphedema]. / Traitement chirurgical des lymphoedèmes.

In our experience, indications for surgical management of lymphedema do not amount to more than 10% of cases. Surgery is significantly complemented by expert pre and postoperative physiotherapy. Excisional procedures are presently seldom carried out, although they may be helpful when carried out as simple "orange-slice"-type resection, or as the Thompson operation. Liposuction is an attractive alternative, but its effectiveness needs be confirmed yet. Actually, the most effective types of surgical treatment are microsurgical lymphovenous or lymphoveno-lymphatic bypass. Secondary lymphedema of the lower extremities (more rarely of the upper limbs) are primary indications. The Campisi-Casaccia team from Genoa has acquired interesting experience with congenital lymphedema. Results relating to surgical treatment of lymphedema can be assessed only after a follow-up of 3-5 years. About one third of cases, on average, do very well and another third do well. Elastic support of the leg must practically always be maintained.

[A survey of the French-speaking Association of Lymphology on the use of pressotherapy in France during the treatment of lymphedema]. / Enquête de l'Association de Lymphologie de langue française sur la pratique de la pressothérapie en France au cours du traitment des lymphoedèmes.

116 physicians out of the 1000 who were questioned use pressure-therapy in the treatment of lymphedema of the extremities. Another 170 are interested in the technique and await this report before possibly adopting it. Overall, the devices utilized are compartmented and use discontinued pressure that is asynchronous in relations to heart beat; each session lasts 30 minutes, on average, with compression and resting phases lasting 45 seconds and 15 seconds, respectively. The usual schedule is one session daily, three days per week, in two series clustered within a single year. Although manual drainage of lymphatics is combined with pressure-therapy in 71.55% of the times, only 43.47% of physicians use elastic support following the treatment. Results are good or very good in 64.4% of cases, and the incidence of post-therapeutic events is rather low (polyuria, pain recrudescence of lymphangitis, etc.). Aside from lymphedema, venous insufficiency, hypodermitis and leg ulcers may also benefit from pressure-therapy.

[Radio-anatomical study of the calcaneus. Accuracy of Böhler's angle measurement]. / Etude radio-anatomique du calcanéum. Validité de la mesure de l'angle de Böhler.

The authors have studied variations of Böhler's angle by various radiographic incidences. They have defined anatomic references of this angle on the correspondent dry bone. With the same radiographic incidences, Böhler's angle was 32 degrees. This value remained constant when X-ray incidences were modified with 15 degrees in all the directions from the external profile. Anatomic variations of the 3 references on dry bone which define this angle, were very small. Böhler's angle is therefore a good morphologic reference for evolutive study of each patient. It's variation in population needs comparative radiographic control of the opposite side.

[Results of emergency repair of wounds of palmar collateral nerves of the fingers]. / Résultats de la réparation en urgence des plaies des nerfs collatéraux palmaires des doigts.

A group of 107 patients with 110 injured digital nerves was studied one year after microsurgical nerve suture. Return of sensibility was tested within the autonomous zones for the nerve. Four tests were used to appreciate the results: pain, Tinel sign, Weber two point discrimination test, the return of the sensibility appreciated by the patient himself. At follow-up, 86 per cent of the patients were found without pain, 75 per cent without Tinel sign, 68 per cent achieved a two point discrimination test of < or = 7 mm, 18 per cent were found with a discrimination test value of 9 mm or more. 93 per cent were satisfied or very satisfied. Of the factors studied, the patient's age at the time of nerve suture was found to be directly related to the return of sensibility as tested by two point discrimination test. Although the return of sensibility following nerve suture in adults is not as good as in children, primary suture of the nerve is worthwhile, a protective sensation is better than an anesthetic digit, and the incidence of painful neuroma is very minimal. The findings in the present study indicate that the nerve suture gives better results that the nerve graft.

[Arthrodesis of the wrist in manual workers. Apropos of 36 cases]. / Arthrodèses du poignet chez le travailleur manuel. A propos de 36 cas.

We present a review of 36 patients with final radiocarpal arthrodesis done between 1976 and 1987. The series was homogeneous: patients were about 40 years old and lesions were work-related. The most frequent reason for the arthrodesis was fracture of scaphoid bone, followed by Kienbock's disease complex trauma of carpus, severe carpal sprain, and articular fracture of the distal fourth of radial bone. Thirty-one arthrodeses were done by screwed-on iliac graft, 5 by nailing following Mannerfelt technique. The two main factors in functional results were pain and loss of strength. The latter averaged 41 per cent of that of the normal side, and only 8 wrists were completely free of pain. Indications for final radio-carpal arthrodesis are discussed, taking into account the poor functional results and their repercussions on social and professional life of the patient.

[Osteogenic exostosis of the first rib: a rare etiology of thoracic outlet syndrome. Apropos of a case]. / Exostose ostéogénique de la première côte: une étiologie rare de syndrome de traversée thoraco-brachiale. A propos d'une observation.

The osteogenic exostosis of the ribs are unfrequent. Their location on the first rib is exceptional. One case is described. The authors, after a review of the literature, recall the particular symptomatology which can be observed, like thoracic outlet syndrome. A partial or total resection of the first rib is advocated. The surgical approach has to be discussed.

[Professional absenteeism and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients]. / Interruption professionnelle et chirurgie des syndromes du canal carpien. Résultats d'une série prospective de 233 patients.

AIM: The aim of our work was to evaluate the influence of the type of patient's insurance ant the return to work interval after carpal tunnel release. MATERIAL AND METHODS: An prospective analysis of 233 patients (18-65 years old, full time workers) undergoing a carpal tunnel release between January and June 1998 was conducted to determine the interval between surgery and return to work. For statistical analysis we used the Ms Works and Status software package. The mean return-to-work intervals were determined for the following and compared for three groups. Group 1: independent worker, n = 87; group 2: wage earner, n = 90; group 3: civil servant, n = 56; and 4 others subgroups: manual workers, n = 164; non manual workers, n = 69; patients with social security insurance, n = 191; patients with workers compensation, n = 42. RESULTS: For the patients in group 1 the average return to work was 17 days (11 days for non manual workers, 29 days for manual workers). In group 2, the average was 35 days (21 days for non manual workers, 42 for manual workers). In group 3 the average was 56 days (49 days for non manual workers and 63 days for manual workers). The statistical analysis showed the civil servant took significantly longer to return to work than independent workers or wage earner (p < 0.05). The work related patients took significantly longer than patients covered by social security. The effect of occupational han (manual versus non manual) use was clear in the group 1 and 2, but there was no difference in the group 3. DISCUSSION: Our study of 233 patients demonstrated significant difference between independent workers, wage earners, and civil servants in term of return-to-work intervals. In comparing manual and non manual workers, we found a significant difference in group 1 and 2, but in civil servants group non difference were found. We cannot explain these findings on medical grounds.