Chihab Taleb

Nerve Repair in Telemicrosurgery: An Experimental Study

Since the development of microsurgery in the 1960s, the prognosis of peripheral nerve lesions has greatly improved. However this new techniques evolution has remained limited by human factors, in particular by physiological tremor. Telesurgery, a technique used in other surgical fields, was developed in the 1990s. This study assesses the feasibility of peripheral nerve repair using telemicrosurgery. Anatomical material from three subjects of different species (rat, pig, and human) was used. The telesurgical step of the procedure was performed with a Da Vinci S robot (Intuitive Surgical, Inc., Sunnyvale, CA). Four anatomical epiperineural repairs were performed. Another neurotrophic repair was performed with a nerve regrowth guide. Regardless of the type of repair performed, the telemanipulator removed the physiological tremor factor. The suture needle was distorted when held by two clamps at a time. Repairs were all performed without any damaging twisting movements of both nerve ends. Our results demonstrated that telesurgery allows very safe and precise peripheral nerve repairs by counteracting physiological tremor and by improving the overview of the surgical field, either with an anatomical or a neurotrophic technique.

The future of robotics in hand surgery

Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.

Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases.

UNLABELLED The rate of malunion after distal radius fractures is 25% after conservative treatment and 10% after surgery. Their main functional repercussion related to ulno-carpal conflict is loss of wrist motion. We report a retrospective clinical series of minimally invasive osteotomies. The series consisted of 9 cases of minimally invasive osteotomies with volar locking plate fixation. All osteotomies healed. The average pain was 5.3/10 preoperatively and 2.1/10 at last follow-up. The mean Quick DASH was 55.4/100 preoperatively and 24.24/100 at last follow-up. Compared to the opposite side, the average wrist flexion was 84.11%, the average wrist extension was 80.24%, the average pronation was 95.33% and the average supination was 93.9%. With similar results to those of the literature, our short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion. TYPE: Case-series. LEVEL OF EVIDENCE IV.

The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures.

Background Open reduction and internal fixation (ORIF) using a volar locking plate is a common method for treating displaced distal radius fractures. There is, however, the risk of extensor tendon rupture due to protrusion of the screw tips past the dorsal cortex, which cannot always be adequately seen on a lateral fluoroscopic view. We therefore wished to compare the sensitivity of an intraoperative fluoroscopic skyline view to a lateral fluorosocopic view in detecting past pointing of these screws. Material and Methods Our series included 75 patients with an average age of 59 years who underwent volar locked plate fixation of a displaced distal radius fracture. Intraoperative anteroposterior (AP), lateral, and skyline fluoroscopic views were performed in each case. The number of screws that were seen to protrude past the dorsal cortex of the distal fracture fragment were recorded for both the lateral and skyline views. The number of screws that required exchange was also documented. Results No screws were seen to protrude past the dorsal cortical bone on the lateral fluroscopic views. 15 of 300 screws (5%) were seen to protrude past the dorsal cortex by an average of 0.8 mm (range, 0.5 to 2 mm) and were exchanged for shorter screws in 11/75 patients. Conclusion Our results demonstrate that the skyline is more sensitive than a lateral fluoroscopic view at demonstrating protrusion of the screws in the distal fracture fragment following volar locked plate fixation. Level of Evidence IV.

ARTHROSCOPIC ASSISTED PERCUTANEOUS SCREW FIXATION OF BENNETT'S FRACTURE

Several techniques are used for fixation of Bennetts fractures. The aim of this study was to assess a technique of arthroscopic-assisted reduction and percutaneous cannulated screw fixation of Bennetts fractures. Seven patients (mean age 29 years) with three fractures Type I and four fractures Type II according to Gedda were operated under arthroscopic lavage, fluoroscopic screw fixation, and arthroscopic control of the joint reduction. Arthroscopy, showed satisfactory joint reduction in all cases. At 4.5 months, the mean pain score was 1 (0-4), QuickDASH 15 (0-61), and Kapandji score 9 (5-10). Compared to the contralateral side, first web opening was 86% (58-100), key pinch 73% (45-89), grip strength, and 85% (40-100). Four secondary displacements were noted, two of which had a step of more than 1 mm. Our results showed that the use of arthroscopy for percutaneous screw fixation of Bennetts fractures facilitates joint reduction but does not guarantee stability of fixation.

Percutaneous fixation of first metacarpal base fractures using locked K-wires: a series of 14 cases.

The treatment of choice for first metacarpal base fractures is surgical. Open fixation is stable but causes tendinous adhesions. Percutaneous fixation is minimally invasive but is often followed by secondary displacement. Herein, we describe an alternative approach that combines advantages of both techniques through increasing stability of the Iselin technique by externally connecting the K-wires. Our series included 13 men of mean age 28 years. There were 13 fractures, 6 of which were extra-articular; there were 7 Bennett fractures, 5 of which had a large fracture fragment. After reduction, two 18 mm K-wires were driven medially crossing the 3 cortices of the first and second metacarpals. After bending them at 90-degree angles, the K-wires were connected externally in a construction allowing adaptation of the gap between the K-wires. Gentle immediate mobilization was allowed and the K-wires were removed 6 weeks later in clinic. At 16-month follow-up, mean pain score was 0.2/10 and Quick DASH was 2.9/100. Pinch grip was 81.8% of the contralateral side and grip strength 91.2%. The first web space opening was 79.1%. There was 1 secondary displacement with a good final result and 2 malunions. No arthritis was noted, but the follow-up was short. Our results show that the Iselin technique using locked K-wires is minimally invasive, stable, allows immediate mobilization, and K-wire removal in the office. Its indications may be extended to all fractures of the base of the first metacarpal whether articular or extra-articular.

Treatment of benign bone tumours of the hand using osteoscopy

Curettage and bone grafting are used traditionally to treat benign bone tumours of the hand. Some authors are proposing minimally invasive treatment using endoscopy. Our purpose is to standardise this technique based on a study of the number and locations of entry points. This is a report on three benign metacarpal bone tumours treated with three different endoscopic approaches: multiportal, extended uniportal and oblique uniportal. In theory, the multiportal approach has several drawbacks: weakening of the bone cortex, a limited visual field and seepage of injectable phosphocalcic cement. The extended uniportal approach causes cortical defects, unacceptable in a minimally invasive technique. The oblique uniportal approach seems less troublesome; vision of the bone cavity is good, curettage of the tumour is complete, the bone cortex is undamaged and there is no leakage of injectable phosphocalcic cement. All things considered, the oblique osteoscopic uniportal approach seems to be the best option for the management of benign bone tumours of the hand.

Metacarpophalangeal joint arthroscopy in the fingers other than the thumb: Retrospective comparison of horizontal versus vertical traction

The goal of this study was to compare the advantages and disadvantages of horizontal versus vertical traction by reviewing a small series of metacarpophalangeal (MCP) joint arthroscopy in the fingers other than the thumb. Our series included eight patients operated with traction placed along the axis of the operated finger. In four cases, traction was applied horizontally and in the other four, it was applied vertically. Arthroscopy was performed using dorsomedial and dorsoradial portals. The fluoroscopy unit was placed either vertically or horizontally as required. The average duration of patient set-up was 17.75min in the horizontal traction group and 32min in the vertical traction group. The average tourniquet time was 56.75min in the horizontal traction group and 71min in the vertical traction group. Horizontal traction required an additional procedure that can potentially compromise surgical asepsis. Vertical traction was less comfortable for the surgeon and horizontal placement of the fluoroscope increased the risk of compromised asepsis. Overall, arthroscopy of the MCP joint of the fingers other than the thumb is an easy technique, indicated for trauma-related and chronic lesions, which may be best performed with horizontal traction.

Enlargement of the flexor pulleys by an omega plasty: A study comparing the release of one or both sides of the A2 and/or A4 pulley.

PURPOSE The omega plasty on one side of the A2 and/or A4 pulley improves the gliding of repaired flexor tendons in zone II. The purpose of this study was whether or not the enlargement of the digital channel was better after the release of one or both sides of each pulley. METHODS In fresh cadavers, the technique was to first disinsert the ulnar attachments of the A2 and A4 pulleys and then the radial insertions. An ultrasound was used to measure the large axis, the circumference, and the cross-sectional surface of each of A2 and A4 pulleys before release, after ulnar release and after radial release. RESULTS The release of the A2 pulley reduces the risk of conflict in the sutured flexor tendons in the digital channel. The release of the A4 pulley seems less effective than that of A2. The release of the two pulleys reduces the risk of conflict in one sutured zone of the flexor tendons in the digital channel. CONCLUSION In all, if there is a conflict between the flexor tendons sutured opposite A2, we recommend an omega plasty on the two sides of the pulley. If the conflict appears opposite A4, we recommend the plasty of the two sides of A4 and A2.

Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: A series of 38 cases

Regardless of the treatment used, 25 to 45% of scaphoid fractures do not heal. Open surgery compromises vascularization and destabilizes ligament attachments. The aim of this retrospective study was to assess the value of retrograde percutaneous screw fixation of Alnot stage IIA and IIB scaphoid non-union in Schernberg zones 2 to 4. This series included 38 patients with a mean age of 31 years. Based on the Alnot classification, there were 16 stage IIA non-unions (12 in zone 3 and 4 in zone 2 according to the Schernberg classification) and 22 stage IIB non-unions (9 in zone 3 and 13 in zone 2). The time elapsed between the initial trauma and the surgical treatment was 10 months on average. Percutaneous retrograde fixation was performed with a cannulated 2.7mm compression screw. At 25 months follow-up, 31 of the non-union cases had healed (81.6%), of which 14 were stage IIA (87.5%) and 17 were stage IIB (77.3%), after an average 6.3 months. Average pain was 1.6. The average Quick DASH was 17.3/100. Compared to the opposite side, the average range of motion was 84.8% in flexion, 84.7% in extension, 98.9% in pronation, 96.5% in supination, 96.8% in ulnar deviation and 86.4% in radial deviation. The grip strength was 80.4% of the contralateral side. Seven patients did not heal after screw fixation; four of them healed after additional electromagnetic stimulation and three after addition of a vascularized bone graft. Based on this studys results, stage IIA non-unions can heal with simple retrograde percutaneous screw fixation. The same procedure could be enough for stage IIB non-union cases, however we recommend adding a cancellous bone graft by arthroscopy. Open surgery procedures are preferred when percutaneous procedures have failed.