Complete ring finger avulsion: Review of 16 years of cases at a Hand Emergency Unit.

Replanting complete ring avulsion injuries remains a challenge for hand surgeons. The prognosis depends on achieving satisfactory function. We present the results of our 16 years' experience with managing this type of injury. Our cohort consisted of 83 cases of complete ring avulsion injuries in patients with an average age of 23.5 years, treated in a Hand Emergency Unit between 1998 and 2014. Seventy-two were replanted. A vein graft was used in 57 cases to bridge the arterial injury and direct anastomosis was performed in 15 cases. Forty-one cases were a microsurgical success. Twenty-four patients were reviewed with an average follow-up of 87 months. The mean of total active motion was 164°, with 64° range of motion in the proximal interphalangeal joint on average. The two-point discrimination for sensitivity averaged 6mm. Two cases of severe cold intolerance were noted. Using a graft for vascular repair increases the odds of microsurgical success. The functional outcome depends on the condition of the proximal interphalangeal joint. Cold intolerance and lack of sensitivity have little effect on the functional outcome and patient satisfaction. Replantation of complete digital avulsion injuries should be attempted. Amputation at the metacarpal base is better discussed later on, after the initial surgery.

[Total knee arthroplasty for recent severe fracture of the proximal tibial epiphysis in the elderly subject]. / Arthroplastie totale de genou pour fracture récente grave de l'épiphyse tibiale proximale chez le sujet âgé.

PURPOSE OF THE STUDY: Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects. MATERIAL AND METHODS: Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized. RESULTS: Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up. DISCUSSION: Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.

[Conservative surgery in Kienbock's disease with perilunate arthrosis: articular resurfacing using resected carpal bones]. / Chirurgie conservatrice dans la maladie de Kienböck avec arthrose périlunarienne: resurfaçage articulaire grâce au principe dit du "carpe banque".

We present 2 cases of Kienböck's disease in which peri-lunate chondral lesions contra-indicated classical procedures such as proximal row carpectomy or 4 corner arthrodesis. A partial carpectomy provided us with an osteochondral graft, used to resurface the areas of chondral damage over the capitate or on the radius. The clinical and radiological result was stable at a follow-up of 3 and 6 years. In the first case, degenerative changes over the head of the capitate contra-indicated proximal row carpectomy. The lunate was removed and the proximal 2/3 of the scaphoid were shifted medially and fused in a "four-corner"-like arthrodesis. In the second case, the lunate fossa on the radius was damaged. The proximal row was excised and an osteochondral graft was harvested from the triquetrum. This was used to replace the lunate fossa on the radius. This new concept of a "carpal bank" has enabled us to extend the classical indications for proximal row carpectomy and four-corner arthrodesis. It makes it possible to withdraw the limits of conservative wrist surgery in Kienböck's disease and we believe this concept could also be extended to similar situations of localized chondral damage in small joints.