Christian Dumontier

Acromioclavicular dislocations: Treatment by coracoacromial ligamentoplasty

We did a retrospective review of 32 patients who had undergone acute treatment for acromioclavicular joint dislocation (mean follow-up period 46 months) and 24 patients who had undergone surgery for chronic joint dislocation (mean follow-up period 51 months). All patients had a ligamentoplasty performed using the coracoacromial ligament. With the shoulder functional score described by Patte, we obtained 81% satisfactory results for the patients who underwent acute treatment and 79% satisfactory results for those who underwent late treatment. Because results in both groups were similar, we now treat only the more severe form of acute dislocation with surgery. Delayed surgery is indicated in those patients who have an unsatisfactory result after functional treatment.

Rotator interval lesions and their relation to coracoid impingement syndrome

In the last 10 years we have found impingement of the coracoid process on the rotator interval in 12 patients (14 shoulders). Seven of these patients were women and 5 were men; the average patient age was 48.5 years. One patient had a calcified coracohumeral ligament, another patient had an anterior tear of a repaired deltoid flap, and a third had an aberrant pectoralis minor tendon inserted into the rotator interval. Eleven patients had a weak rotator interval, and in 4 cases the rotator interval had a small tear. We closed the rotator interval in all 12 patients. We also performed a coracoidoplasty in 5 of the patients. The condition of all shoulders improved clinically after operation; the average follow-up was 4.2 years. Three patients (4 shoulders) still had moderate pain, and 7 patients (9 shoulders) lacked strength. Internal rotation was the only shoulder movement that remained limited. Although impingement seemed obvious during surgery, experimental studies have reported contradictory findings.

Entrapment and compartment syndromes of the upper limb in haemophilia

17 patients with haemophilia have been treated for a neurological deficit of the upper limb. Four of the five entrapment neuropathies have been operated upon, and only two patients recovered completely. Only two of the 12 patients with a compartment syndrome have been operated upon, and only two had sequelae. Clotting factor replacement is always indicated as primary treatment. Surgical release is indicated if the condition fails to improve. Late treatment was responsible for incomplete recovery, whatever the cause of the nerve compression.

The middle radioulnar joint and triarticular forearm complex

The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The radius and ulna are connected by three joints, the proximal, middle, and distal radioulnar joints. The forearm ensures pronation/supination and longitudinal load transfer. The biomechanical and clinical relevance of the proximal and distal radioulnar joints is well established. In contrast, the middle radioulnar joint was considered relatively unimportant until studies published in the last decade showed that it fulfils crucial biomechanical functions and is of considerable clinical significance. We believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a triarticular complex that functions as a full-fledged entity. In this concept, the three forearm radioulnar joints (proximal, middle, distal) work together to provide stability, mobility and load transfer. Here, we will argue for the relevance of the triarticular complex concept based on published data about forearm biomechanics and pathological conditions.

Penetrating Volar Injuries of the Hand: Diagnostic Accuracy of US in Depicting Soft-Tissue Lesions

PURPOSE To evaluate the effectiveness of ultrasonography (US) in depicting lesions of the tendons, arteries, and nerves caused by penetrating wounds of the volar aspect of the hand, with surgical exploration as the reference standard. MATERIALS AND METHODS Consecutive patients seen at one center over a 2-month period in 2006 were prospectively included. The institutional review board approved the study, and each patient gave written informed consent. There were 30 injuries in 26 patients (19 men and seven women; median age, 34 years). US examination was performed before surgery. Surgeons were not informed of the US findings. For tendons, arteries, and nerves, the sensitivity, specificity, positive predictive value, and negative predictive value of US were computed. RESULTS US depicted all tendon lesions, with no false-positive findings; two arterial lesions were missed, with no false-positive findings, and four nerve lesions were missed, with six false-positive findings. The negative predictive value was 100% (95% confidence interval: 95.5%, 100%) for tendons, 96.7% (95% confidence interval: 88.7%, 99.6%) for arteries, and 93.7% (95% confidence interval: 84.5%, 98.2%) for nerves. In three cases, US depicted foreign bodies missed at surgery. CONCLUSION US was highly effective in identifying patients with no tendon or arterial lesions. Performance was poorer for diagnosing nerve lesions. US followed by a repeat physical examination after 72 hours to look for missed nerve damage may deserve evaluation as an alternative to routine surgical exploration when US findings are normal.

Difficultés du transfert d’information en vue d’un consentement éclairé: Étude expérimentale chez 21 patients

Purpose of the study Delivering information to the patient, an ethical obligation recognized for years, has recently become a legal obligation. Proof of information delivery has become the legal responsibility of the surgeon. We conducted a prospective study to evaluate the quality of information transfer by assessing patient comprehension of information delivered in an orthopedic surgery unit.PURPOSE OF THE STUDY Delivering information to the patient, an ethical obligation recognized for years, has recently become a legal obligation. Proof of information delivery has become the legal responsibility of the surgeon. We conducted a prospective study to evaluate the quality of information transfer by assessing patient comprehension of information delivered in an orthopedic surgery unit. MATERIAL AND METHODS All patients attending consultations before undergoing arthroscopic treatment for rotator cuff tendinopathy were enrolled in this study when the consultation was conducted in the presence of an observer. Two questionnaires, one for the patient and one for the surgeon, were used to collect given information about the pathological condition, the modalities of treatment, and the expected results of the treatment and its complications. RESULTS All 21 patients included in the study considered they had been well informed and that they had understood their pathological condition as well as the complications of the proposed treatment. However, agreement between their stated comprehension and the information delivered was poor, varying from 15 to 50%. Furthermore, 90% of the patients stated they had understood the potential complications of the surgical procedure, despite the fact that the consulting surgeons had not (generally) provided information on such complications. DISCUSSION There is a gap between what the surgeon says (or thinks he/she says) and what the patient understands. Potential biases in this study (non-unbiased observer) might explain this discordance which was probably related to the unequal relationship between the patient and the physician for any consultation. Therefore, the basis of informed consent cannot be found in the details concerning complications actually delivered to the patient. Surgeons must become aware that the patients understand very little of their explanations. This does not mean that the information should not be delivered but on the contrary that it must be. The important point is not necessarily the information content but rather the quality of the human relationship enabling information transfer.Resume Situe au cœur de l’ethique medicale, le devoir d’information concerne tout particulierement le chirurgien orthopediste, appele, de par sa discipline, a porter atteinte a l’integrite physique d’autrui pour des raisons purement fonctionnelles. Pour savoir si l’information etait correctement transmise au cours d’une consultation, nous avons realise une etude prospective sur l’information recue lors d’une consultation pour des lesions chroniques de la coiffe des rotateurs relevant d’un traitement arthroscopique pendant qu’un observateur assistait a la consultation. Au cours de notre etude, nous avons montre qu’il existait une difference importante entre l’information donnee par le medecin et l’information comprise et retenue par le patient. La concordance entre l’information donnee par le chirurgien et celle retenue par le patient variait de 15 a 50 %. Des lors, la validite du concept du consentement eclaire est mise en doute si l’information qui doit le preceder n’est pas accessible au patient. La question ethique qui se pose aux chirurgiens est de savoir comment rendre cette information accessible aux patients, non pas pour pouvoir se defendre aupres des tribunaux, mais pour donner aux patients tous les elements necessaires a la prise de decision finale.

Locked metacarpophalangeal joint of long fingers: classification, definition and treatment based on 15 cases and literature review.

OBJECTIVES The purpose of this study was to clarify the definition, classification and treatment of the disorder known as the locked metacarpophalangeal (MCP) joint of long fingers, through the analysis of 15 cases and a literature review. PATIENTS AND METHODS We carried out a retrospective study of 15 patients with locked MCP joint of long fingers, all treated between 1997 and 2007. All patients underwent some imaging investigations including lateral, anteroposterior and Brewerton X-ray examinations. All these patients had been treated by surgery, which allowed us to describe the concerned lesions. RESULTS The patients were 47 years old on average, 70% of the locks involved the index and the middle finger. Twelve fingers were locked in flexion. In nine of these cases, the cause was a blocking due to a clinging of the radial or ulnar accessory collateral ligament that overlapped a prominent metacarpal condyle or an osteophyte of the metacarpal head. Three fingers were locked in extension due to an imprisonment of a strap of the palmar plate. One patient was lost to follow-up. The remaining 14 patients had an average follow-up of 12.6 months. All recovered normal mobility without any recurrence. CONCLUSION This study and the literature review show that there are in fact two clinical presentations depending on the etiologies. We suggest a modification of both Posners definition and Harveys classification; a new classification should focus on the causes depending on the clinical presentation of the locking, so as to improve the correlation between clinical presentation, etiology and treatment.

The Forearm Joint

The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The forearm ensures pronation/supination and longitudinal load transfer. The radius and ulna are connected by two anatomical joints, the proximal, and distal radio-ulnar joints. The biomechanical and clinical relevance of the proximal and distal radio-ulnar joints is well established. However we believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a tri-articular complex that functions as a fully-fledged entity i.e. the “forearm joint”. The middle radio-ulnar joint fulfils crucial biomechanical functions and is of considerable clinical significance and should no more be ignored. New clinical tests and imaging techniques may show its pathology that may require a surgical treatment as the three forearm radio-ulnar joints (proximal, middle, distal) must work together to provide stability, mobility and load transfer.

Tratamiento y rehabilitación de las lesiones de los nervios periféricos

Resumen El tratamiento rehabilitador de un paciente con una lesion nerviosa periferica es un trabajo largo y dificil. Es preciso repetir periodicamente las evaluaciones del diagnostico kinesiterapeutico ya que se trata de un proceso evolutivo. A partir de los datos fisiologicos que se recuerdan en este articulo, el kinesiterapeuta adapta sus tecnicas de rehabilitacion al paciente, a sus posibilidades de recuperacion y a sus necesidades funcionales y profesionales. Debe ensenarle a protegerse y a potenciar al maximo sus capacidades, ya que las secuelas son frecuentes y requieren a veces el aprendizaje de compensaciones.