F. Lebailly

Prospective continuous study comparing intrafocal cross-pinning HK2® with a locking plate in distal radius fracture fixation

The fixation of distal radius fractures by pinning or locking plates remains controversial. The aim of this prospective continuous study was to compare the results of 28 anterior locking plates with 23 intrafocal cross-pinning HK2(®) systems. The mean age of group I (SVP(®), SBI™ plate) was 61 years. There were 15 extra-articular and 13 articular fractures. The mean age of group II (HK2(®), Arex™) was 63 years, with 13 extra-articular and 10 articular fractures. Twelve clinical variables were measured: pain, wrist strength, supination strength, pronation strength, quick DASH score, range of wrist motion in flexion, extension, pronation, and supination, ulnar variance, radial slope, and radial volar tilt. At 40 weeks follow-up, there was no difference between the two groups for 10 variables; two variables showed differences between the two groups: mean quick DASH score was 10.7 for group I, 19.7 for group II, and mean ulnar variance was -0.95 mm for group I, and 1.16 mm for group II. Six transient complications were noted for group I: five tenosynovitis, and one carpal tunnel syndrome. We noted 12 complications in group II: four superficial infections, two secondary displacements, one pin migration, two CRPS type II, two tendon ruptures and one nerve irritation. Generally, plates provided a more stable fixation associated with less complications while the HK2(®) system was quicker and less costly. The indications for its use need to be refined with a larger series and longer follow-up.

Telerobotic manipulation of the brachial plexus.

OBJECTIVE This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery. METHODS After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patients head, and the microsurgical steps were performed by using robotic telemanipulation. RESULTS The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation. CONCLUSION Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.

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.

The MetaHUS(®) fixation system versus pinning and plating in 5th metacarpal neck fractures.

The treatment of fifth metacarpal neck fractures is controversial. The aim of this work was to modify the intermetacarpal pinning technique with an external connector, and to compare the results of this modified technique to those of intramedullary pinning and locking plate techniques. Our series included 56 extra-articular fractures of the neck of the fifth metacarpal treated by intramedullary pinning (group A), locking plate Aptus(®) MEDARTIS™ (group B) and MetaHUS(®) Arex™ (group C); the last one consisted in intermetacarpal percutaneous pinning and connecting the pins externally. There were no statistically significant differences for all criteria except active mobility, which was less important for group B. In groups A and B, 6 complications were noted, in group C, one. Our results showed that blocked intermetacarpal K-wires is a technique of choice for the treatment of displaced fifth metacarpal neck fractures, not only because it is easy to assemble and to remove, but also because it allows immediate active mobilization.

Are Pedicled Flaps Feasible in Robotic Surgery? Report of an Anatomical Study of the Kite Flap in Conventional Surgery Versus Robotic Surgery

Reconstruction of cutaneous defects of the hand has dramatically progressed. It should also benefit from the development of robot-assisted surgery. The aim of the present study was to consider the feasibility of a kite flap in robotic surgery. Two cadaver hands were used in this study, one for a conventional procedure, and one for a robotic surgical procedure using a da Vinci Si robot. The operative duration was measured, and all difficulties encountered during the procedures were reported. The total duration of the intervention was 19 minutes with the conventional procedure and 30 minutes with the robotic technique. Some difficulties were encountered, related both to lack of specific instrumentation and haptic feedback. Robotic surgery presents interesting advantages such as the suppression of physiological tremor, increased degrees of freedom, and enhanced precision and accuracy of hand maneuvers. In this study, it allowed the realization of a pedicled flap without any external help.

Contribution of arthroscopy in case of septic appearance arthritis of the wrist: a nine cases series.

Septic arthritis of the wrist is a diagnostic and therapeutic emergency. Synovectomy and lavage by arthrotomy is often followed by stiffness. The purpose of this study was to evaluate the diagnostic and therapeutic contribution of emergency arthroscopic synovectomy with intraarticular lavage. Nine patients were operated on for wrist pathology with septic appearance. All had signs of local inflammation, three showed locoregional inflammation, three were febrile. In one patient several joints were involved. Seven patients presented with inflammatory or degenerative arthritis. All patients underwent emergency surgery using radiocarpal joint puncture, arthroscopic exploration, intraarticular lavage and synovectomy at both the radiocarpal and midcarpal joints. The results were evaluated by pain, Quick DASH, grip strength, and wrist range of motion. In three cases, joint fluid appeared clear, in three it was turbid, and in three purulent. Gram stain and culture revealed bacteria in four cases. Synovitis was radiocarpal four times, radiocarpal and midcarpal once. In one case, there was radiocarpal and midcarpal chondritis. Average pain was 5.3/10 preoperatively and 2/10 at the last clinical follow-up visit. Mean grip strength was 23.3 kg on the involved side vs. 33.5 kg on the opposite one. Mean flexion was 55° for the involved wrist vs. 68°; mean extension was 52° for the affected wrist vs. 59°. No patient was reoperated on. In all cases, there was no sign of local inflammation, regional lymphadenopathy or systemic infection at the last follow-up. One patient died of colon metastatic cancer. Another patient developed a severe Complex Regional Pain Syndrome type I (CRPS1). Our results suggest three principles of management of wrist arthritis with septic appearance: extended surgical indication, emergency operation and arthroscopic procedure.

Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15 mm approach: Feasibility study

Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist.

Is It Useful to Assess Both QuickDASH and PRWE Scores

Objective/Hypothesis: Scoring systems are widely used in medicine and surgery. During the last decade, the reduced version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) has established itself as the main Patient Reported Outcome Measures (PROMs) questionnaire used by hand surgeons. Another measurement tool can be used when the condition affects more precisely the wrist: the Patient-Rated Wrist Evaluation (PRWE). The aim of this study is to find out how correlated these 2 scores are. Materials and Methods: More than 2000 wrist clinical evaluations (including QuickDASH and PRWE), performed for any kind of condition the last 2 years, were gathered and analyzed. Spearman’s rank correlation coefficient was used to compare the visual analogue scale (VAS) score for pain, QuickDASH, and PRWE values. Results: There is a high correlation between these 3 subjective scores. Spearman’s rank correlation coefficient reaches .70 when assessing VAS and QuickDASH, .73 when assessing VAS and PRWE, and .86 when assessing PRWE and QuickDASH. Conclusions: With the statistical power that provides a huge sample, it is proven that QuickDASH and PRWE scores are highly correlated. Thus, we can abandon one of them to spare time without loosing relevant information.

Arthroscopic Scapholunate Posterior Capsulodesis Cadaveric Preliminary Study Comparing Transosseous Tunnels and Suture Anchors

Objective/Hypothesis: Arthroscopic capsuloligamentous dorsal repair in chronic scapholunate (SL) tear (Mathoulin) has become a common surgical option. Questions remain about this technique: Are there always strong enough remaining parts of the ligaments? Is the 3/0 absorbable stitch strong enough to stabilize SL complex in any cases? We propose 2 modified procedures: one using transosseous fixation and another one using suture anchors. The aim of this study is to assess and compare the primary stabilization of the SL complex. Materials and Methods: Ten fresh cadaveric wrists were used. One wrist was excluded because of severe radius malunion and arthritis. SL instability was created by cutting scapholunate interosseous (SLIO) ligament, dorsal radio carpal (DRC), and dorsal inter carpal (DIC) carpal insertions under arthroscopic control. The dorsal capsule in front of SL area was carefully spared. A synovectomy was performed. A 3-4 enlarged extra capsular approach was used: through a 10 mm transverse incision, the third and fourth compartments were opened, leaving the dorsal capsule unharmed. SL stabilization was performed using suture anchors for 5 wrists (group 1). Through the 3-4 enlarged extra capsular approach, the dorsal capsule was pierced with 2 Micro CorkScrew (Arthrex, Napples, Florida, USA), one was fixed in scaphoid proximal pole and the other one in posterior horn of lunate. Each strands of the lunate anchor were firmly knotted with each strands of the scaphoid anchor. SL stabilization was performed using transosseous sutures for 4 wrists (group 2). Through the 3-4 enlarged extra capsular approach, 2 tunnels were drilled through the proximal pole of scaphoid and the posterior horn of lunate. A fiberwire (Arthrex, Napples, Florida, USA) was passed through the dorsal capsule and through the tunnels passing by the mid carpal joint. A U-shaped self locking knot was performed. SL instability was evaluated before and after surgical procedures using European Wrist Arthroscopy Society (EWAS) arthroscopic classification and fluoroscopic measures of SL angles and SL diastasis. At the end of the procedures, large longitudinal dorsal approaches were performed. Lesions of the tendons, nerves, and cartilage were reported. Results: Fluoroscopic initial evaluation shows normal SL angles and no SL diastasis, except for one wrist of group 2 which already had SL instability. Arthroscopic initial evaluation found EWAS stage 3C to 5 instability. In group 1, stabilization was obtained for 3 wrists (EWAS stages 1, 1, and 2). One wrist was not stabilized (EWAS 4). There was 1 anchor loosening. In group 2, procedure could not be achieved because of fracture of the scaphoid tunnel in 2 cases. The wrist with static instability was fairly stabilized: diastasis 7 to 1 mm, SL angle from 15° to 70°, and EWAS stage from 5 to 1. One wrist was only partially stabilized (EWAS stage from 4 to 3C). Except for the osteochondral lesions of scaphoid in group 2, no iatrogenic lesions were observed. Conclusions: Transosseous tunnels are a difficult procedure and can lead to osteochondral lesions. Anchors seemed to be easier and to provide fair primary stabilization. Secondary stabilization should be evaluated in a clinical study.