C. Fontaine

High-Frequency Ultrasonographic Examination of the Finger Pulley System

The purpose of this study was to determine the ability of high‐frequency ultrasonography to provide for direct evaluation of the annular and cruciform finger pulley system.

Second generation Guepar total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases

BACKGROUND Osteoarthritis of the thumb basal joint is the most common location for hand degenerative joint disease. First, carpometacarpal (CMC) joint arthroplasty is one treatment option. The purpose of this article is to present the outcome of the GUEPAR II prosthesis, a total trapeziometacarpal cemented implant of the retaining ball-and-socket design type. Numerous other advantageous features of this implant, second generation of an earlier version are explored. HYPOTHESIS Clinical and radiological results confirm the GUEPAR II trapeziometacarpal arthroplasty as a reliable and efficient evolution of earlier prosthetic designs. MATERIALS AND METHODS Eighty-four GUEPAR II prostheses were implanted to treat advanced and severely incapacitating first CMC osteoarthritis. The average follow-up time in this collaborative series (from 2 centers) was 50 months. RESULTS There were no intraoperative complications and no dislocations at the final follow-up evaluation, 92% of patients were satisfied or very satisfied with their results with objective improvement of their Kapandji score. Strength was closely comparable to the nonaffected side. Radiographic studies at the final follow-up evaluations did not show (except in one socket revision instance) signs of implant loosening. On occasion, non-progressive radiolucent lines were observed. More than 80% of the patients remained pain free. CONCLUSIONS In our series, GUEPAR II total joint arthroplasty of the thumb CMC joint has proven to be efficacious, improving motion, strength, and achieving a high degree of pain relief. Successful outcome appears in our experience contingent upon strict compliance with numerous surgical technique details. Current research focuses on improving bipolar fixation by developing press-fit cementless implants.

Contribution à l’innervation du muscle subscapulaire: À propos de 18 dissections

INTRODUCTION Dividing the subscapularis muscle along its fibers axis allows approaching the glenohumeral joint. The more medial its division, the more possible injury of its nerve supply. AIM The aim of our study was to assess the subscapularis nerve supply through cartography of the entry points of subscapularis nerves from simple landmarks, reproducible by triangulation. MATERIAL AND METHODS On 18 formalin-preserved shoulders, after dissection of the subscapularis nerves, distances were measured between entry points of subscapularis nerves and the following landmarks: center of the minor tubercle (tm), upper and lower poles of the glenoid cavity (cgs and cgi), apex of the coracoid process (pc). RESULTS There were in average 3.33 subscapularis nerves (2-4). These different nerves split most often before entering subscapularis muscle; there were in average 5.05 entry points (3-6). Distances between entry points and clinical landmarks were as follows: cgs, 3.9-6.45 cm; cgi, 3.7-5.54 cm; tm, 5.9-7.15 cm; pc, 4.9-7.66 cm. Reporting these measurements onto a frame allowed to show that all these points were located in average medially to the scapular notch and at more than 3 cm from the anterior border of the glenoid cavity. CONCLUSION If the transverse division does not extend farther than 3 cm from the anterior border of the glenoid cavity and from the medial border of the root of the coracoid process, there should not be any injury of the subscapularis nerves.Resume Introduction la division du muscle subscapulaire dans le sens de ses fibres permet d’aborder l’articulation scapulo-humerale. Plus sa division est poussee medialement, plus une lesion de son innervation est possible. Buts le but de notre etude etait d’apprehender l’innervation du muscle subscapulaire en realisant une cartographie des points de penetration des nerfs subscapulaires a partir de reperes simples et reproductibles par triangulation. Materiel et methodes sur 18 epaules formolees, apres dissection des nerfs subscapulaires, les distances ont ete mesurees, entre les points de penetration nerveux et les reperes cliniques suivants: centre du tubercule mineur (tm), bords superieur et inferieur de la cavite glenoidale (cgs et cgi), apex du processus coracoide (pc). Resultats il y avait en moyenne 3,33 nerfs subscapulaires (2-4). Ces nerfs se divisaient le plus souvent avant de penetrer dans le muscle subscapulaire ; il y avait en moyenne 5,05 points de penetration (3-6). Les distances entre les points de penetration et les reperes cliniques etaient les suivantes : cgs, de 3,9 cm a 6,45 cm ; cgi, de 3,75 cm a 5,54 cm ; tm, de 5,9 cm a 7,15 cm ; pc, de 4,9 cm a 7,66 cm. Le report de ces mesures sur une maquette montrait que tous ces points se situaient en moyenne en dedans de l’incisure scapulaire et a plus de 3 cm du bord anterieur de la cavite glenoidale. Conclusion a condition que l’incision transversale ne s’etende pas a plus de 3 cm du bord anterieur de la cavite glenoidale et ne depasse pas le bord medial du pied du processus coracoide, les nerfs du muscle subscapulaire ne devraient pas etre leses.

Predictors of radial nerve palsy recovery in humeral shaft fractures: A retrospective review of 17 patients

BACKGROUND Radial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. HYPOTHESIS Factors predicting the outcome of radial nerve palsy can be identified. METHODS Of 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12-84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. RESULTS Of the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. DISCUSSION These findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. LEVEL OF EVIDENCE IV, retrospective study with no control group.

Reply to the letter by D. Ollat and F. Chaise

We are grateful to D. Ollat and F. Chaise for their interest in our rticle on foot-drop correction and for their contribution. Regarding Achilles tendon lengthening, our group has considerble expertise with the method described by Piriou et al. (reference 5 in the article) and included in our treatment strategy. This rocedure is not performed percutaneously. Instead, a mini-open pproach is used, with two short incisions that provide visual conrol and allow accurate adjustment of the amount of lengthening. Regarding the type of transfer, we previously reviewed the outomes of 73 patients treated using our technique then re-evaluated y an independent observer. This review found no evidence of a arus-inducing effect, even in the long term (reference 13 in the rticle). Regarding the rehabilitation programme, whether the duration f immobilisation is 5 or 6 weeks is of minimal relevance. Howver, since writing our article, we have noticed, together with our atients, that meaningful benefits are derived from cautious ambuation in the resin cast and a walking boot (references 15 and 17 in he article). Finally, regarding the loss of sensation at the sole of the foot, he first main author now spends more time in Africa working on

Bases anatomiques de la neurotomie tibiale : étude morphométrique, histologique et IRM

But de l’etude la neurotomie tibiale constitue l’une des modalites therapeutiques de la spasticite des muscles de la loge posterieure de la jambe. Le plus souvent realisee par voie poplitee, elle est directe sur les nerfs du m. gastrocnemien et le n. superieur du m. soleaire, indirecte sur le n. inferieur du m. soleaire, les nn. des mm. tibial posterieur (TP), long flechisseur de l’hallux (LFH) et des orteils (LFO), apres reperage electrophysiologique per-operatoire. L’objectif de cette etude est de preciser le niveau d’origine des branches du n. tibial, ainsi que d’etudier en histologie les differents faisceaux qui le constituent. Un reperage de ce nerf en IRM est egalement propose. Materiel et methodes 50 membres inferieurs ont ete disseques. Une etude histologique (microscopie optique et electronique) a egalement ete realisee, ainsi qu’une etude preliminaire en IRM. Resultats le n. inferieur du m. soleaire nait en moyenne a 16 mm en dessous de l’arcade du soleaire, le n. du TP a 37 mm (2 nn. dans 9/50 cas), le n. du LFH a 61 mm (2 nn. dans 6/50 cas), le n. du LFO a 48 mm (2 nn. dans 1/50 cas). Une branche motrice commune est retrouvee dans 17 cas, parfois visible en IRM. L’etude histologique confirme la naissance des branches motrices a la partie antero-laterale du nerf. Conclusions ce travail confirme les donnees de l’electrophysiologie per-operatoire et permet une dissection intra-fasciculaire plus precise, permettant de limiter les risques de troubles sensitifs et trophiques post-operatoires.

Étude morphométrique du rameau profond du nerf ulnaire. Application à l’hyponeurotisation du nerf ulnaire dans le traitement de la spasticité

Introduction L’un des traitements de la spasticite du membre superieur est l’hyponeurotisation du rameau profond du nerf ulnaire (RPNU), c’est-a-dire la section partielle des branches destinees aux muscles intrinseques spastiques, pour en diminuer la spasticite sans les paralyser. L’intervention est menee par un abord du canal de Guyon. L’hyponeurotisation ne peut etre directe que sur les muscles hypothenariens ; elle est indirecte sur les interosseux et les thenariens profonds, c’est-a-dire que le chirurgien recherche la localisation approximative des fascicules dont la stimulation per-operatoire entraine la contraction des muscles cibles et les coupe partiellement. Cette seconde methode est approximative et peut donner des effets non proportionnels sur les deux groupes musculaires. Le but de cette etude etait de preciser le niveau d’origine de toutes les branches du RPNU, d’etudier leur disposition intra-neurale et de proposer une technique operatoire. Materiel et methodes 15 membres superieurs formoles ont ete disseques sous loupes. Les distances entre le niveau d’origine de toutes les branches du RPNU et la ligne bistyloidienne ont ete mesurees et chaque branche a subi une dissection intra-neurale aussi poussee que possible. Resultats Les branches destinees aux hypothenariens naissaient peu apres la bifurcation du nerf ulnaire ; celles destinees aux interosseux naissaient de la convexite (versant disto-medial) du RPNU, celles pour les thenariens profonds de sa partie terminale. Au sein-meme du nerf, les branches pour les interosseux couraient dans le fascicule medial, celles pour les thenariens profonds dans le fascicule lateral ; ces deux fascicules peuvent etre trouves au sein du RPNU apres microdissection.

Contribution à l’étude du cercle vasculaire épicondylien latéral du coude : description d’une artère musculo-périostée radiale constante

La vascularisation peri-articulaire du coude est bien connue. Neanmoins, certains auteurs negligent ou privilegient certains axes. Cette etude precise la constitution du cercle epicondylien lateral : une artere musculo-periostee radiale, jamais decrite a notre connaissance, retrouvee constamment, collaterale de l’artere brachiale, est decrite, elle participe largement au reseau perioste lateral. Les arteres et veines de 12 membres superieurs dont 10 frais ont ete injectees au latex. Les vaisseaux peri articulaires ont ete disseques, mesures dessines et photographies. Les arteres destinees au squelette sont musculo-periostees. Le schema classique fait jouer un role preponderant a l’artere profonde du bras de laquelle nait l’artere collaterale radiale, satellite du nerf radial. Nous ne retrouvons pas ce schema : il existe deux plans au reseau epicondylien lateral : 1) un plan superficiel de faible importance, forme par l’artere collaterale radiale (artere nerveuse irriguant le nerf radial) qui s’anastomose avec les branches anterieures de l’artere recurrente radiale, longeant la capsule ; 2) un plan profond forme par une artere musculo-periostee radiale qui penetre le muscle brachial, lui fournit quelques branches avant de devenir periostee et de vasculariser la partie antero-laterale articulaire de l’extremite distale de l’humerus. Cette artere s’anastomose avec le tronc principal de l’artere recurrente radiale qui envoie de multiples rameaux au col radial. L’artere collaterale mediane n’est qu’une artere musculaire, nous n’avons jamais observe sa participation au cercle epicondylien lateral. Cette etude precise l’apport arteriel de la portion antero-laterale articulaire de l’extremite distale de l’humerus.