Coverage of skin defect due to losses of substance in the elbow.

Skin defects of the elbow follow severe trauma or bone exposure after skin necrosis, osteitis, or management of infected pseudarthrosis. The orthopedic and plastic management of these lesions is fundamental. The authors describe the different clinical frameworks that can lead to bone and/or joint exposure. Before, during or at a distance from bone management (external fixation, internal fixation, temporary cementoplasty, bone graft…), they detail the surgical techniques aimed at covering skin defects of the elbow. The authors review simple skin replacement techniques such as Z-plasties, emphasizing the interest of pedicled flaps of the arm and forearm, as well as muscle or fascio-cutaneous flaps, which are able to cover almost all the elbow skin defects.

Soft tissue coverage options around the knee.

Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.

Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb.

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

Management of complex forearm defects: A multidisciplinary approach.

Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.

[Treatment of necrosis of Achilles tendon without tendon reconstruction: About four cases]. / Traitement des nécroses du tendon d'Achille sans reconstruction tendineuse : à propos de quatre cas.

INTRODUCTION: Management of the combined loss of Achilles tendon and skin is difficult. However, these are not exceptional situations after Achilles tendon surgery. Data from the literature are extensive and there is currently no consensus on the technique of tendon reconstruction. CASE REPORTS: We report four cases of purulent necrosis of the Achilles tendon complicating longitudinal incision or suturing of a tendon rupture. After debridement of necrotic tissue, the defect was covered either by a fasciocutaneous perforating flap or a thin skin graft without reconstruction of the underlying tendon. DISCUSSION AND CONCLUSION: The functional results are very satisfactory with good joint mobilities and a resumption of walking without lameness for all patients. Fibrosis can reconstitute a true neo-tendon confirmed on MRI. The advantages are many compared to other methods: a single operating time is necessary, the postoperative management is simple and it avoids certain technical difficulties related to tendon reconstruction. A larger series would be needed to support these results.

[Secondary digit reconstruction of mutilated hand]. / La chirurgie secondaire après amputation digitale traumatique.

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case.

[Pediatric lower extremity reconstruction]. / Reconstruction des traumatismes complexes des membres inférieurs chez l'enfant.

Lower limb multi-tissular injuries are rare in children but require elaborate surgical care considering the child's growth potential, donor-site morbidity and the psychological consequences for the child and his family. This review outlines the various coverage options, from simple to more complex, developing their principles and their results. Technical features of wound repair of the lower limb in children will be detailed. An efficient and ambitious care can give excellent functional outcomes in children, even when extended, multi-tissue lesions members are involved.

[Traumatic hand injuries in children]. / La main traumatique de l'enfant.

Hand injuries in children are frequent in pediatric emergencies. Epidemiology of hand injuries in children depends on age and social context. The management of these injuries requires experienced pediatrics in order to obtain a functional hand to preserve the potential growth and to reduce the risk of cosmetic sequelae. We will describe the specificities of hand trauma in children and their therapeutic principles.

[Description of an original conservative method for the surgical management of the Blauth IIIb thumb hypoplasia: "relative lengthening - thumb stabilization"]. / Apport d'une technique originale de chirurgie conservatrice dans la prise en charge des hypoplasies du pouce de type IIIb : « l'allongement relatif-stabilisation de la colonne du pouce ¼

PROBLEMATIC: Thumb hypoplasia is a rare congenital hand disorder. Despite the recent clarifications concerning many surgical indications, dealing with Blauth IIIb type remains a polemic subject. We hereby suggest "The relative lengthening - thumb stabilization", an original and simple conservative surgery technique for the Blauth IIIb type, in order to satisfy parents and big kids requests of a "five fingered hand". The whole hypoplastic thumb is lowered in a way that lengthens it relatively. An intentional pseudarthrosis is performed between the first metacarpal base and the second metacarpal diaphysis, creating a "new trapeziometacarpal joint". PATIENTS AND METHODS: The suggested technique was performed on four IIIb type hypoplasic thumbs of three kids since 1997. RESULTS: The average postoperative follow-up is 9.6years (3.5 to 12.5years). The average Kapandji score is 5.75 (5 to 6). The key pinch prehension strength is by 21.5% in relation to the normal hand and the global prehension strength (according to Jamar Test) is by 67%. The global pinch is possible and natural in all cases. DISCUSSION AND CONCLUSION: The surgical management of the type IIIb thumb hypoplasia is a real challenge. We regard this technique of relative lengthening with thumb stabilization as an interesting alternative to the other microsurgical conservative surgeries.

Wrist fusion in peripheral paralysis.

In cases of paralysis of the upper limb, wrist fusion is useful in selected indications, especially when there are little to no tendon transfers available to restore finger function and wrist extension. Wrist fusion is particularly useful in the sequelae of brachial plexus lesions and in total paralysis of the radial nerve with hand drop and preserved wrist flexors. Numerous fusion techniques have been proposed. In cases of sequelae of brachial plexus lesions, locking of pronation-supination is associated with the wrist fusion. The use of anatomical plates has dropped the non-union and complication rates.

[Blauth classification of thumb hypoplasia: thought and proposition of modification]. / La classification de Blauth des hypoplasies du pouce : réflexion et proposition de modification.

Using the conclusions of the previous article concerning the therapeutic indications for handling hypoplastic thumb, we suggest an amendment to the current Blauth classification. This alteration is based on the management of this congenital anomaly, whereas the Blauth classification describes the morphological characteristics of the malformation. It appears for us more usable in practice by its easiness to be memorized.

Anatomic basis of ulnar index metacarpal reverse flow vascularized bone graft for index distal bone loss.

Well-known advantages of vascularized bone grafts led us to determine the anatomical basis of a metacarpal vascularized bone graft to find a solution for distal index bone loss. Seventeen adult human hands from fresh cadavers were dissected and analyzed. For each hand, we studied the second dorsal metacarpal artery, the ulnar dorsal proper digital artery of index, and the ulnar palmar proper digital artery of the index. Location, diameters, origins, and anastomoses were observed, and at the end, the vascularised bone graft was raised. The second dorsal metacarpal artery was present in all hands, always arising from the dorsal carpal arch with a 1-mm mean diameter. The ulnar dorsal proper digital artery of index was isolated on all dissections, with a subcutaneous location on the ulno-dorsal side of the proximal phalanx. The mean diameter of ulnar dorsal proper digital artery at the level of index proximal phalanx was 0.4 mm. We found anastomotic branches between the ulnar dorsal and palmar proper digital artery of index at the level of the proximal phalanx which permitted us to elevate a vascularised bone graft. We succeeded in removing the graft in all specimens. Its pivot point was always more distal than the middle of the proximal phalanx. The arc of rotation allowed the graft to reach the distal phalanx in 80% of the cases. This anatomical study has demonstrated the theoretical possibility of a reversed pedicled bone graft taken from the ulnar neck of the second metacarpal. This graft brings the following benefits: (a) the use of a minor vascular axis, (b) a surgical technique with a dorsal approach allowing the elevation and the use of the graft at the same time. It can be used on the index for failures of DIP joint arthrodesis, huge chondroma, or traumatology.

[Does the thumb have two phalanges or three? Development of ideas since Aristotle]. / Le pouce a-t-il deux ou trois phalanges ? Evolution des idées depuis Aristote.

Many controversies mark the long road of the history of anatomy. The hand is not exempt of them. Even Galen's clear thinking, founded on the strict determinism between the structure of an organ and its function, and based on animal dissection, was criticized. In view of the structural complexity of the hand, we will limit our study to one of the most symptomatic conceptual disagreements: whether the human thumb has two or three phalanges, according to whether we include the first metacarpus, or if the thumb's first phalanx is considered as the initial element. According to the latter theory, there is a missing element in the first digital row, and this missing element is the metacarpus. This theory is ancient and its evolution throughout history is discussed in our study. Finally, we explain the origin and bases of the reasoning that led us to suggest the word 'metaphalanx' to designate the first metacarpus.

Long-term functional outcomes after surgical treatment of nonspecific thoracic outlet syndrome: Retrospective study of 70 cases at a mean of 8 years' follow-up.

Our objective was to study the clinical and functional outcomes after surgical treatment of nonspecific thoracic outlet syndrome (TOS) using a supraclavicular approach. We included every patient with TOS who was treated surgically by the same surgeon at a single hospital between 1999 and 2014 with a minimum follow-up of 4 years. The primary outcome was the overall evaluation of the function by the QuickDASH Score. Secondary outcomes included functional, subjective outcomes, pain levels, and neuropathic features. The clinical outcome of 70 cases was evaluated with a mean follow-up of 8.5 years. The improvement in the QuickDASH Score was significant with an average change of 38 points. Mean pain intensity was reduced postoperatively by 1.6 points from 5.1/10 to 3.5/10. Persistent pain rate at 4/10 or more remained in 56% of cases. These cases were mostly neuropathic. The surgical procedure significantly reduced the number of patients suffering from paresthesia, numbing or weakness. The possibility of sequelae and the persistence of neuropathic pain means the surgical indication should be limited to patients with significant functional disability despite well-conducted rehabilitation. The long-term functional outcomes in patients undergoing TOS was mostly good but could be improved by addressing residual neuropathic pain symptoms.

[Trapeziectomy and ligamentoplasty with Gore-Tex: preliminary results on 43 patients with trapeziometacarpal joint arthritis]. / Trapézectomies et ligamentoplasties de suspension au Gore-Tex((R)) : résultats préliminaires sur 43 arthroses trapézométacarpiennes.

OBJECTIVES: Trapeziectomy with suspension tendinoplasty is one of the most frequent procedures for the treatment of trapeziometacarpal arthritis of the thumb. The authors describe a new technique of total trapeziectomy and suspension tendinoplasty with Gore-Tex nonabsorbable monofilament. They give radiological and clinical results of their first 43 procedures with a minimum follow-up of 18 months. METHODS: Forty-two patients (43 thumbs), average age of 61 years, underwent this procedure. According to Comtet's classification, they were 16 stage 1, 17 stage 2 and 10 stage 4. RESULTS: At 30 months average follow-up, 93% patients had good results on pain (Alnot's stage 0 or 1). The average opposition was 9.5 out of 10 according to Kapandji and the angle between the two first metacarpals was 36.5 degrees. The average key-pinch force was equal to 4.8 Kg. The average DASH score was 14.2. Collapse of the trapezial space was constant in the radiological study and at the follow-up, the trapezial space ratio was 63% of the preoperative ratio. The most frequent complication was reflex sympathetic dystrophy found in nine patients. The satisfaction rate was 88% and 93% of patients would agree to repeat this procedure. CONCLUSION: Our technique of suspension tendinoplasty with Gore-Tex monofilament has comparable results with those published with other transplants (Flexor carpiradialis, palmaris longus, abductor pollicis longus...). Our technique has some advantages over others: simplicity of surgical procedure without the need to harvest a tendon, no morbidity at the donor site and less time taken for the procedure. However, it still retains the advantages of suspension tendinoplasty.

[Free dermal fat graft for coverage of the median nerve following failed carpal tunnel release]. / Le greffon dermohypodermique pour la couverture du nerf médian au poignet: résultats cliniques et paracliniques.

OBJECTIVES: We wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release. METHODS: Eight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI). RESULTS: Five patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13 kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases. CONCLUSIONS: Free dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results.

Surgical management of closed, isolated proximal phalanx fractures in the long fingers: Functional outcomes and complications of 87 fractures.

Finger fractures are the most common skeletal injuries of the upper limbs. The purpose of this study was to evaluate the functional outcomes and complications after surgical management of isolated, closed fractures of the proximal phalanx (PP) of the hand (thumb excluded). Surgical management was indicated in 87 PP fractures. Fractures were reduced and fixed with pins, screws or a plate. Functional outcomes were assessed through the range of motion (ROM) in flexion-extension, hand and finger strength, and the QuickDASH and PRWHE scores. Fixation was done with pins in 32 cases, screws in 41 cases, and a plate in 14 cases. Rehabilitation was started an average of 1.7 weeks after surgery. There was no significant difference in the functional outcomes based on either fracture type or surgical approach. Nevertheless, the following significant differences were observed: PRWHE score (P=0.017) by injured finger; proximal interphalangeal (PIP) ROM (P=0.037) by fixation type; and grip strength (P=0.019), Quick DASH (P=0.017), and PRWHE (P=0.045) by rehabilitation delay. The most common clinical complications were minor malrotation and cold intolerance. Radiological assessment showed complete union in all cases. Surgical management of PP fractures leads to good functional outcomes, including a satisfactory recovery of finger ROM. The functional recovery of a fractured digit is dependent on the right fixation choice, complete bone union, and early rehabilitation. We suggest using screw fixation to achieve patient satisfaction and optimal functional recovery of closed, isolated PP fractures of the long fingers.

Bilateral fracture of the base of the middle phalanx in a climber: Literature review and a case report.

During climbing, tears of the annular pulley are the most common injuries, while fractures of the dorsal base of the middle phalanx are rare and atypical. Only a few cases have been reported in international literature. The authors present a case of a Salter-Harris type III fracture of the base of the middle phalanx of the middle finger in a young climber and a review of the literature. The patient was a 17-year-old boy who regularly and intensively practiced climbing. He consulted for a non-traumatic history of proximal pain of the interphalangeal joints of the middle fingers. On clinical examination, there was pain on the dorsal surface of the proximal interphalangeal joints, with no decrease in range of motion of the fingers. X-rays showed a Salter-Harris type III, displaced epiphyseal fracture of the dorsal base of the middle phalanx of the middle fingers. Conservative treatment resulted in fracture union and the patient had recovered normal activity of his hand at the 6-month follow-up. Stress fractures are common in athletes like climbers in response to repetitive and prolonged sports. Epiphyseal fractures are the most common injuries in young climbers.

[Mycobacterium marinum tenosynovitis of the abductors]. / Ténosynovite des fléchisseurs à Mycobacterium marinum.

INTRODUCTION: Infection with Mycobacterium marinum is rare and usually produces cutaneous lesions. We report here two cases of tenosynovitis of abductor muscles. CASE: The first case presented isolated involvement of the abductors of the left thumb, and the second the abductors of the middle finger. In both cases, the bacteriological examinations found M. marinum. Antibiotic therapy for three months with rifampin and clarithromycin cured the infection. DISCUSSION: These cases of tenosynovitis followed deep inoculation. A mycobacterial infection should be considered in cases of synovitis, especially when limited to an area of the hand in patients without other rheumatic disorders.

Secondary mobilization of the first dorsal metacarpal artery flap for first web space reconstruction in a child: A case report.

The authors report the case of an iterative mobilization of a skin flap based on the first dorsal metacarpal artery. This flap was initially associated with a toe-to-hand transfer to provide adequate skin coverage in the reconstruction of a post-traumatic thumb defect in a 5-year-old child. More than 8years after initial surgery, this flap was mobilized again for recovery of the first web space opening, which was retracted. This case illustrates the possibility of remobilizing the first dorsal metacarpal artery flap to reduce donor site sequelae in children.