Functional and radiographic evaluation of the treatment of traumatic bone loss of the hand using the Masquelet technique.

This study was a retrospective evaluation of 18 patients with traumatic bone loss affecting the fingers, hand and wrist who were treated using the induced-membrane technique. Sixteen men and two women, mean age 54years (27-74) presented a hand injury including bone loss. Sixteen patients were treated on an emergency basis and two following nonunion of their fractures. There were 13 cases of open fracture of the phalanx and 5 cases of metacarpal fractures. These patients were treated with debridement and the injuries were covered when necessary. To address the bone loss, the first step of the induced-membrane technique involved placing a cement spacer (polymethylmethacrylate [PMMA]) without antibiotics in the defect. During the second step, the cement spacer was removed and replaced by autologous cancellous bone graft. The graft was placed within the biological tube left empty after removal of the cement. For each patient, bone union was assessed with radiographs and/or CT scan. Failure was defined as nonunion at 1year. In 16 patients, the fractures had healed after 4months (1.5-12months) on average. Two failures were noted (one nonunion treated using a PIP prosthesis and one case of delayed union). Mobility of the fingers, evaluated using the Total Active Motion (TAM) was 145° (75°-270°). The Kapandji score reached 8 for the thumb. Grip strength reached 21kg/F and pinch strength was 5kg/F; these values were 50% of those in the healthy hand. The induced-membrane technique is simple and can be used to treat traumatic bone loss in an emergency, thus avoiding amputation and limb shortening, while preserving limb function. It provides immediate stability and allows early mobilization.

Can computer-assisted surgery help restore leg length and offset during THA? A continuous series of 321 cases.

INTRODUCTION: Total hip arthroplasty (THA) can bring about complications - particularly leg length differences - that are becoming increasingly litigious. Computer-assisted orthopedic surgery (CAOS) can help optimize the procedure, but its ability to effectively restore leg length is controversial. As a consequence, we carried out a study to determine: (1) its contribution to meeting leg length and offset objectives, (2) its reliability, by evaluating the correlation between radiological and navigation data, (3) its safety, by evaluating navigation-specific and non-specific complications. HYPOTHESIS: CAOS will help to restore leg length within ± 5 mm in more than 80% of cases. MATERIAL AND METHODS: A series of 321 continuous cases of cementless THA implanted through the posterolateral approach using CAOS was analyzed retrospectively. With a minimum 1 year follow-up, we evaluated whether the leg length and offset goals were achieved, how well the navigation and radiology data were correlated and whether navigation-specific and non-specific complications occurred. Based on our hypothesis that 80% of patients would have less than 5 mm leg length difference and the null hypothesis (PA = P0) with an alpha of 0.05, 200 observations were required to achieve a power of 90%. RESULTS: The leg length and offset objectives were achieved in 83.3% and 88% of cases, respectively. Twenty-two patients required a heel wedge to compensate for leg length differences. The correlation between the radiology and surgical navigation data was satisfactory - the Pearson coefficient was 0.79 for length and 0.74 for offset. Intraoperative and postoperative complications or adverse events were found in 14.6% of cases; these were specific to CAOS in 12.1% of cases and non-specific in 2.5% of cases. CONCLUSION: This study shows the relevance of CAOS for achieving preoperative leg length objectives, with good correlation between navigation and radiology data, and without major complications. LEVEL OF EVIDENCE: IV - retrospective study.

Comparison of the reliability of leg length and offset data generated by three hip replacement CAOS systems using EOS™ imaging.

INTRODUCTION: Computer-assisted orthopaedic surgery (CAOS) theoretically will help to optimise total hip arthroplasty (THA) results. Although CAOS systems have become more sophisticated, they are not widely used, partially because of their suspect reliability. To assess reliability of these systems, we carried out a study with multiple objectives in mind: (1) establish and compare the accuracy of the leg length (LL) measurement from three CAOS systems; (2) analyse the correlation of LL and offset data generated by these CAOS systems with those of the EOS™ imaging system; (3) determine if the goals of leg length restoration with ±2 and ±5 mm were achieved; (4) evaluate why certain cases fails. HYPOTHESIS: The three CAOS systems have the same accuracy for LL, and their error is less than or equal to 0.6mm. MATERIAL AND METHODS: We retrospectively studied 106 cases of primary THA where preoperative and postoperative measures of leg length had been performed with an EOS™ imaging system. The cases were placed in three groups, depending on which CAOS system had been used: group A (Amplivision™, amplitude), group B (Hip Express™, Brainlab), group P (THS™, Praxim). The accuracy of the leg length data was calculated by finding the difference between the data from each CAOS system and the gold-standard EOS measurements. RESULTS: The leg length accuracy was -0.846 [-5 to 9], -0.675 [-9 to 18] and 0.542 mm [-5 to 13], respectively for groups A, B and P. The accuracy was significantly lower in group A than B (P=0.044) and group P (P=0.038). The Pearson correlation coefficient for CAOS and EOS measurements was 0.189, 0.701 and 0.891 for leg length and 0.668, 0.202 and 0.680 for offset, for groups A, B and P, respectively. No difference between groups were observed relative to the leg length objectives being achieved within ±2 mm (P=0.61) and ±5 mm (P=0.314). There were no differences in terms of the number of CAOS failures: three in group A, one in group B and three in group P (P=0.06). CONCLUSION: The Praxim™ and Brainlab™ CAOS systems had similar accuracy for leg length measurements, and both were better than the Amplitude™ system. Only the Praxim™ had an error of less than 0.6mm. All the CAOS systems had values less than 1mm, which is considered excellent. LEVEL OF EVIDENCE: Level IV, retrospective study.

Reconstruction of closed rupture of thumb flexor tendon pulleys with a single free palmaris longus tendon graft: a case report and review of literature.

Closed rupture of thumb flexor tendon pulleys is extremely rare. Several techniques have already been described for finger pulley reconstruction. Various techniques based on prior anatomic and biomedical studies have been proposed for thumb pulley reconstruction, in which one or two of the three pulleys are replaced. In the present study, we describe an original technique using a single, free palmaris longus (PL) autograft for thumb pulley reconstruction.

[Major upper limb trauma: patients' outcomes in 22 cases]. / Macro-amputation du membre supérieur : que sont devenus les patients ? À propos de 22 cas.

In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.

[Total trapeziectomy and suspension ligamentoplasty: is there any interest to interpose a pyrocarbon Pi2® implant?]. / Trapézectomie totale et ligamentoplastie de suspension : une interposition par un implant Pi2® en pyrocarbone a-t-elle un intérêt ?

Total trapeziectomy with suspensioplasty remains one of the most widely used techniques in thumb osteoarthritis. Nevertheless, such a technique does not completely prevent collapse of the trapezial space. We wanted to know whether adding a pyrocarbon spacer allowed better keeping trapezial space and increasing strength. We compared two groups of patients matched on sex, age, manual labor and dominant side. In each group, they were 23 patients suffering from CMC1 osteoarthrosis, mean age was 62 years. Surgical technique consisted in a total trapeziectomy and suspensioplasty with a Gore-Tex(®) slip without spacer (group A) or associated with spacer Pi2(®) (group B). The follow-up was 25 months for group A and 15 months for group B. Height of the scaphometacarpal space represented 81.5% of trapezium height in group B versus 61.6% in group A. Better correction of hyperextension of the metacarpophalengeal joint was noted in group B. Between group A and group B, no difference was found according to pain (VAS 1.6 versus 1/10), mobility (opposition 9.44 versus 9.31; commissural opening 35.2° versus 37.2°) or strength (Jamar 19.1kg/F versus 16.8kg/F, pinch 4.35kg/F versus 4.67kg/F). DASH score was 16.9 and 25.1/100 respectively. We deplore three symapthetic reflex dystrophies in group A and seven radiological subluxations of the implant in group B. The total trapeziectomy with suspensioplasty gave satisfactory results for both series. The implant Pi2(®) seems to contribute keeping trapezial height, without functional advantages and with a risk of dislocation.