Franck-Marie Patrick Leclère

[Collagenase injection in Dupuytren's disease, evaluation of the ultrasound assisted technique].

Since October 2011, the enzymatic lysis of Dupuytrens cord was introduced in Switzerland (Xiapex(®), Auxilium Pharmaceuticals, Pfizer). Here we present our first university experience and underline the major role of ultrasound during the injection. Between December 2011 and February 2013, 52 injections were performed to eliminate 43 Dupuytrens cords in 33 patients. The mean age of the patients was 64.4 ± 8.5 years. Complications were documented for each patient. Before, directly after and after a minimum of 6 months post-injection, the contracture of the treated joint was measured with use of a goniometer. The DASH score was evaluated after a minimum of 6 months and the patients were asked to subjectively evaluate the outcome of the treatment (very good, good, mild, poor) and whether they would reiterate it if necessary. Four skin defects, one lymphangitis, and one CRPS were responsible for a complication rate of 18%. There was no infection and no tendon rupture in the series. The mean MCP joint contracture was respectively 36.8 ± 27.4°, 3.5 ± 7.8° (gain of mobility compared to the preoperative situation 33.3°, P<0.001), and 8.4 ± 13.9° (gain 28.4°, P<0.001) respectively before, just after and at the long-term clinical control. The mean PIP joint contracture was respectively 36.5 ± 29.1°, 5.9 ± 6.7° (gain 30.6°, P<0.001), and 15.1 ± 13.8° (gain 21.4°, P<0.001) respectively before injection, just after and at the long-term clinical control. The DASH score decreased from 24 ± 14 to 7 ± 9 (P<0.001). Eighty-one per cent of the patients were satisfied or very satisfied of the treatment. All but two would reiterate the treatment if necessary. Ultrasound is able to target the injection of collagenase in order to reduce complications. The short-term results of this non-invasive therapy are very promising however comparison with conventional procedures is difficult as the long-term results are lacking.

The Role of Dynamic Ultrasound in the Immediate Conservative Treatment of Volar Plate Injuries of the PIP Joint: A Series of 78 Patients.

Introduction: The management of volar plate avulsion fractures in the context of a stable joint and a bony fragment of less than 30% has traditionally been conservative. This study was performed to assess volar plate healing with high-resolution ultrasound in order to provide early full mobilization. Material and Methods: Between January 2012 and December 2013, 78 patients with volar plate injuries of the proximal interphalangeal (PIP) joints (42 distortions and 36 dislocations) were treated conservatively in our department for volar plate avulsion fracture associated with stable joint and bony fragment inferior to 30% of the intra-articular surface assessed both by radiography and ultrasound. Conservative treatment included extension stop splinting for the first 2 weeks and Coban bandage until 6 weeks postinjury. However, it may be possible to modify the duration of extension stop splinting based on clinical and ultrasound findings (with no additional X-ray) performed every 2 weeks for the first 3 months and then at 4 months postinjury. Only patients with residual contracture at the 4-month assessment had prolonged follow-up in order to ensure adequate dynamic splint therapy. Results: The amount of soft tissue oedema and the mobility of the volar plate were factors used to determine return to full mobilization. Mean extension-stop-splint wear was 16 ± 2 days. During the first 2 follow-up assessments, 4 patients were excluded from the study because of the instability of the PIP joint. One patient required refixation of a large fragment of 30%, 2 patients required superficial flexor tendon (FDS) tenodesis of the unstable volar plate in hyperextension and 1 other patient required arthrodesis of the PIP joint. In 51 patients, the postoperative follow-up was free of complications at 4 months. In 18 patients, flexion contracture of 20° (range 11°-40°) and oedema during follow-up required dynamic extension splints for 3 to 5 months. After this time, 5 patients had a residual contracture of 10° to 15°. Conclusion: Avulsion fractures of the volar plate at the PIP joint are common. In general, they have a good outcome using the conservative treatment with extension block splints. Flexion contracture is a common complication and may be reduced by immediate splints in full extension at night and Coban bandage during the day. High-resolution sonography is a convenient tool to evaluate palmar plate stability, to assess reduction of oedema, and thus to guide safe return to full range of movement.

Endoscopically assisted proximal radial nerve decompression: surgical technique.

STATE OF THE ART The proximal radial nerve compression syndrome includes supinator syndrome and proximal radial nerve constrictions. This article presents a new endoscopic assisted radial nerve decompression surgical technique described for the first time by Leclère et al. in 2013. SURGICAL TECHNIQUE Endoscopic scissor decompression of the proximal radial nerve is always performed under plexus anaesthesia. It includes 8 key steps documented in this article. We review the indications and limitations of the surgical technique. CONCLUSION Early clinical results after endoscopic assisted decompression of the radial nerve appear excellent. However, they still need to be compared with conventional techniques. Clinical studies are likely to widely develop because of the mini-invasive nature of this new surgical technique.

Neurotized lateral gastrocnemius muscle transfer for persistent traumatic peroneal nerve palsy: Surgical technique

INTRODUCTION Persistent traumatic peroneal nerve palsy, following nerve surgery failure, is usually treated by tendon transfer or more recently by tibial nerve transfer. However, when there is destruction of the tibial anterior muscle, an isolated nerve transfer is not possible. In this article, we present the key steps and surgical tips for the Ninkovic procedure including transposition of the neurotized lateral gastrocnemius muscle with the aim of restoring active voluntary dorsiflexion. SURGICAL TECHNIQUE The transposition of the lateral head of the gastrocnemius muscle to the tendons of the anterior tibial muscle group, with simultaneous transposition of the intact proximal end of the deep peroneal nerve to the tibial nerve of the gastrocnemius muscle by microsurgical neurorrhaphy is performed in one stage. It includes 10 key steps which are described in this article. Since 1994, three clinical series have highlighted the advantages of this technique. Functional and subjective results are discussed. We review the indications and limitations of the technique. CONCLUSION Early clinical results after neurotized lateral gastrocnemius muscle transfer appear excellent; however, they still need to be compared with conventional tendon transfer procedures. Clinical studies are likely to be conducted in this area largely due to the frequency of persistant peroneal nerve palsy and the limitations of functional options in cases of longstanding peripheral nerve palsy, anterior tibial muscle atrophy or destruction.