D. Lepage

Extra- and intramuscular nerve supply of the muscles of the anterior antebrachial compartment: applications for selective neurotomy and for botulinum toxin injection

Hypertonia of the upper limb due to spasticity causes pronation of the forearm and flexion of wrist and fingers. Nowadays this spasticity is often treated with injections of botulinum toxin and sometimes with selective fascicular neurotomy. To correctly perform this microsurgical technique, it is necessary to get precise knowledge of the extramuscular nerve branching in order to be better able to select the motor branches which supply the muscles involved in spasticity. The same knowledge is required for botulinum toxin injections which must be made as near as possible to the zones where intramuscular nerve endings are the densest, which is also where neuromuscular junctions are the most numerous. Thus, it is necessary to better know these zones, but their knowledge remains today imprecise. The muscles of the anterior compartment of 30 forearms were dissected, first macroscopically, then microscopically, to study the extra- and intramuscular nerve supply and the distribution of terminal nerve ramifications. The results were then linked to surface topographical landmarks to indicate the precise location of motor branches for each muscle with the aim of proposing appropriate surgical approaches for selective neurotomies. Then for each muscle, the zones with the highest density of nerve endings were divided into segments, thus determining the optimal zones for botulinim toxin injections.

Reconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf cas

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Article originalReconstruction des pertes de substance osseuse du membre supérieur par la technique de la membrane induite, étude prospective à propos de neuf casInduced membrane technique for the reconstruction of bone defects in upper limb. A prospective single center study of nine cases

INTRODUCTION Bone defect in the upper limb remain infrequent with few reported in the literature. Their reconstruction raises the problem of bone union of non weight-bearing segments as well as the function of adjacent joints. We report a monocentric continuous series of nine patients treated with the induced membrane technique (Masquelet technique). PATIENTS AND METHODS Nine patients with a mean age of 39.2 years (17-69) presented with a bone defect of the humerus (six cases) or one of two bones (three cases). Diaphyseal (six cases) or metaphyseal (three cases) defects were secondary to trauma in three patients, to non-union in four others and following tumors for the other two. The mean defect was 5.1cm (2.5-9). Reconstruction was done by initial filling using a spacer in cement, followed by a cancellous bone graft within the induced membrane. BMPs growth factor was used in two cases. RESULTS Bone union was achieved in eight out of nine cases with a follow-up of 23 months (8-52) after the first stage, and 17 months (6-49) following filling by the graft. One patient did not want the second stage done before one year. The failure was in a very non-compliant patient who had a bone substitute associated with aBMP. Two septic non-unions were cured. Shoulder and elbow functional outcomes were comparable to the controlateral side for humeral defects; pronosupination decreased by 17% for the cases of reconstruction of two bones. DISCUSSION The technique of the induced membrane allows filling of a large bone defect, while avoiding vascularised bone autografts and their morbidity. It requires two procedures but can be used in emergency or after failure of other interventions. It is a reliable, and reproducible technique where the only limit is the cancellous bone stock. Following the series of Masquelet, Apard and Stafford in the lower limb, and the series of Flamans in the hand, this is the first report of reconstruction of defect in the upper limb using this technique.

Treatment of trapeziometacarpal osteoarthritis by partial trapeziectomy and costal cartilage autograft. A review of 100 cases.

PURPOSE Trapeziectomy remains the surgery of choice in the treatment of trapeziometacarpal osteoarthritis. Some authors consider the collapse of the trapezial space responsible for a loss of strength and intracarpal deformities. We report our experience of partial trapeziectomy with chondrocostal autograft as an interposition material. METHODS The study included100 thumbs in 82 patients with a mean age of 64.6 years (47-82). Mean follow-up was 68 months (4-159). Partial trapeziectomy was carried out through a dorsal approach. The graft was harvested through a direct approach of the 9th rib. RESULTS Our results were similar to those obtained with alternative techniques, except for strength where the gain is improved. No intracarpal deformities were seen. There was no sign of graft wear; the length of the thumb ray is preserved. The results are stable over time, and the morbidity of the costal donor site is negligible. The interposition of a hardwearing biological material and its association with partial trapeziectomy enable to restore the thumb stability and strength.

Post-traumatic reconstruction of digital joints by costal cartilage grafting: A preliminary prospective study

In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15-46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9-25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20-50) for the PIP joint and 37° (30-40) for the MCP joint. Mean total active motion (TAM) was 191° (160-250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8-15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0-47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.

Fractures comminutives du radius distal traitées par ostéosynthèse et substitut osseux injectable : Étude prospective de 39 cas

Resume La comminution dans les fractures du radius distal est un element souvent neglige dans l’analyse de la fracture. La combler permet d’eviter une modification de la variance ulnaire par tassement du foyer fracturaire. Ce tassement peut survenir apres la sixieme semaine, apres l’ablation du materiel, et perturber la pronosupination. L’utilisation de substituts osseux injectables permet de combler la comminution en s’adaptant au defect grâce a leur phase pâteuse quelle que soit leur composition chimique ou leur mode de durcissement qui survient en quelques minutes. Ces substituts ne sont pas des colles ou des adjuvants qui remplacent la fixation osseuse. Les auteurs rapportent leur experience de l’adjonction d’un substitut injectable associe a une osteosynthese dans 48 cas de fracture du radius distal prises en charge entre 1998 et 2001et revus avec un recul moyen de 46 mois (36-56). Quatre perdus de vue et 5 cals vicieux initiaux ont ete exclus de l’evaluation finale. Trois algodystrophies ont ete rapportees. Trente-neuf patients ont pu etre evalues par un operateur independant. Il s’agissait de fractures A dans 26 cas, de fractures B dans 15 cas, et de fractures C dans 7 cas selon la classification de l’AO osteosynthesees par broches (32 cas), par plaque posterieure (14 cas) ou par fixateur externe (2 cas). Le score fonctionnel de Herzberg atteignait 84/100 (54-100), le score radio clinique de Gartland et Werley atteignait 4,6 (0-11) avec 89 % d’excellents et bons resultats, le DASH atteignait 23,6 (5,8-62,7). La variance ulnaire etait inchangee ou s’etait modifiee de moins de 2 mm entre la periode postoperatoire immediate et le plus grand recul dans 88 % des cas. Seule la survenue d’un syndrome du canal carpien apres fuite en avant du substitut a pu etre imputee a celui-ci.

Apport de la radioscintigraphie quantitative dans les traumatismes du poignet avec radiographies initiales normales: Étude prospective de 154 cas

Resume Les fractures du scaphoide carpien doivent etre diagnostiquees rapidement afin d’eviter la pseudarthrose generatrice d’arthrose du poignet a laquelle expose leur meconnaissance. Meme si la plupart des patients beneficient d’un examen clinique minutieux et radiologique adequat, un certain nombre de fractures passent encore inapercues. La radioscintigraphie quantitative est une nouvelle technique d’imagerie medicale, validee dans une etude precedente qui associe scintigraphie osseuse quantitative et fusion numerique entre image scintigraphique et image radiologique. Elle est susceptible de diagnostiquer des fractures occultes au niveau du poignet et l’objectif de cette etude etait d’evaluer la frequence des fractures occultes au niveau du poignet diagnostiquees grâce a la radioscintigraphie quantitative. Une etude prospective a ete menee de novembre 1994 a mars 1999 pour evaluer les resultats de cet examen chez les patients presentant apres un traumatisme du poignet une symptomatologie clinique evoquant un processus fracturaire au niveau du poignet mais avec un bilan radiologique standard juge normal initialement. Avant sa realisation, certains patients avaient beneficie ulterieurement de plusieurs series de radiographies a quelques semaines d’intervalle pour rechercher le pourcentage de fractures devenues secondairement visibles sur les radiographies. Le bilan radiologique des patients a ete revu avec les donnees de la radioscintigraphie quantitative. Cent cinquante-quatre patients ont ete inclus. L’examen radioscintigraphique a permis de diagnostiquer des fractures chez 61 patients dont 56 avec un seul foyer de fracture et 5 avec plusieurs sites fracturaires ; 39,6 % des poignets examines presentaient une ou plusieurs fractures occultes dont 41 % de fractures du scaphoide carpien. Les fractures occultes au niveau du poignet et notamment au niveau du scaphoide carpien sont frequentes. La repetition du bilan radiologique ne permet pas d’augmenter le taux de mise en evidence de ces fractures. La tomodensitometrie peut etre prise a defaut dans la recherche de fractures occultes. L’IRM est l’examen cle dans le bilan d’une symptomatologie fracturaire du poignet mais reste peu disponible actuellement. La scintigraphie osseuse est classiquement peu specifique. La radioscintigraphie quantitative, examen rapidement disponible et peu couteux, semble actuellement le meilleur outil pour diagnostiquer les fractures occultes du poignet. Elle doit permettre d’eviter l’evolution d’une fracture negligee du scaphoide carpien vers la pseudarthrose et l’arthrose, aux consequences individuelles, sociales et medico-legales serieuses.

Nouveau traitement de la maladie de Kienböck avancée : remplacement du semi-lunaire par greffon cartilagineux costal

Treatment of advanced Kienböcks disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböcks disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.

Métastase osseuse du fémur traitée par enclouage centromédullaire: évaluation clinique et radiologique par le score de tokuhashi : À propos de 24 patients

PURPOSE OF THE STUDY Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery. MATERIAL AND METHODS Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty. RESULTS Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score < 3 was 2.1 months. It was 17 months in those whose score was > 6. CONCLUSION Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.Resume Les auteurs rapportent leur experience de l’enclouage femoral alese ou non en cas de metastase femorale fragilisante ou fracturaire. L’indication operatoire etait posee grâce a l’utilisation du score de Tokuhashi, score predictif evaluant le pronostic selon 5 criteres lies statistiquement a la survie : l’etat general du patient, l’etiologie du cancer, l’existence de metastases viscerales, le nombre de metastases osseuses, le caractere fracturaire ou non de la metastase. L’etude retrospective menee entre 1997 et 2000 portait sur 24 patients. Ces metastases touchaient le tiers proximal du femur (massif trochanterien ou region sous-trochanterienne) dans 22 cas. Ces metastases fracturaires ou fragilisantes ont ete traitees par enclouage de reconstruction (20 patients) ou clou centromedullaire standard (4 patients). La moitie des patients operes a presente une complication medicale. Le quart des patients est decede dans le trimestre suivant l’intervention, tous ayant presente une complication medicale. Aucune embolie graisseuse ou pulmonaire n’a pu etre formellement diagnostiquee. La survie etait egale a 2 mois si le score etait inferieur a 3, de 17 mois si celui-ci etait superieur a 6.

Aspects anatomiques et biomécaniques des fractures du radius distal de l’adulte : revue de la littérature

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.