Gilles Dautel

Effect on balance and gait secondary to removal of the second toe for digital reconstruction: 5-year follow-up.

Foot anatomy and lower limb function were analyzed in 11 children (aged 6.5–12.5 y) 5 years after removal of one or two second toes for digital reconstruction. In addition to physical examination and x-rays, postural balance and three-dimensional measurements of gait were analyzed. Among the 15 operated feet, five had bridle scars, three had claw deformities of the third toe, five had pain in the first intermetatarsal space, and seven had overt or early-stage hallux valgus (including five after unilateral toe removal). Hallux valgus deformation was also observed in three nonoperated feet. Maintenance of balance and rate of displacement of the center of pressure when standing on one foot with eyes closed were significantly altered for operated limbs compared with nonoperated limbs. Gait was rapid because of increased step cadence. Foot progression angle and ankle and knee joint sagittal kinematics during walking were normal. Although children appeared to not be affected in their daily life by the removal of the second toe(s), related foot anatomic and functional modifications require further follow-up.

Is total elbow arthroplasty indicated in the treatment of traumatic sequelae? 19 cases of Coonrad-Morrey® reviewed at a mean follow-up of 5.2 years

INTRODUCTION Traumatic sequelae of the elbow are difficult to manage because of bone deformities, changes in joint congruency and bone defects. MATERIALS AND METHODS Total elbow arthroplasty is a therapeutic option when the joint space has disappeared. Nineteen patients underwent semi-constrained Coonrad-Morrey(®) total elbow arthroplasty in 12 cases for post-traumatic elbow arthritis (group 1) and in seven cases for 7 non-union of the distal humerus (group 2). The mean age at surgery was 60 years old (56 in group 1 and 67 in group 2). The mean delay between the initial trauma and arthroplasty was 16 years (group 1) and 22 months (group 2). RESULTS At a mean follow-up of 5.5 years (24-156 months) in group 1, the Quick-DASH score was 34 points with outcomes that were considered to be good to excellent in 75% of the cases according to the Mayo Elbow Performance Score (MEPS). A progressive radiolucency was identified on X-ray in 33% of the cases, and moderate wear of the polyethylene insert in 17%. There were 7 complications (58%) requiring revision in 3 cases (25%). At a mean follow-up of 4.6 years (24-108 months) in group 2, the Quick-DASH score was 39 points with good and excellent results in 86% according to the MEPS. A radiolucency was noted in 28% and moderate wear of the inserts in 14%. There were 2 complications (28%) requiring revision in 1 case (14%). CONCLUSION Semi-constrained total elbow arthroplasties provide recovery of functional range of motion with a stable and pain-free elbow for post-traumatic conditions. The age at surgery is a risk factor for complications. The indication for total elbow arthroplasty in patients under 60 should be carefully considered in relation to alternative treatment options. LEVEL OF EVIDENCE Level IV Retrospective study.

Finger replantation: surgical technique and indications.

In this article, we discuss the surgical technique of finger replantation in detail, distinguishing particularities of technique in cases of thumb amputation, children fingertip replantation, ring finger avulsion, and very distal replantations. We emphasize the principles of bone shortening, the spare part concept, the special importance of nerve sutures and the use of vein graft in case of avulsion or crushing. However, even if finger replantation is now a routine procedure, a clear distinction should be made between revascularization and functional success. The indications for finger replantation are then detailed in the second part of this paper. The absolute indications for replantation are thumb, multiple fingers, transmetacarpal or hand, and any upper extremity amputation in a child whatever the level. Fingertip amputations distal to the insertion of the Flexor digitorum superficialis (FDS) are also a good indication. Other cases are more controversial because of the poor functional outcome, especially for the index finger, which is often functionally excluded.

Is combining massive bone allograft with free vascularized fibular flap the children's reconstruction answer to lower limb defects following bone tumour resection?

PURPOSE OF THE STUDY Bone tumours are frequent conditions in children, and their surgical resection may lead to extensive defects which reconstruction is often challenging. Indeed, local conditions do not promote bone healing, and the achieved surgical result requires to be life-lasting. Capanna suggested a reconstruction technique combining massive allograft and free vascularized fibular flap. The first one is intended to withstand mechanical stress, and the second one offers biological and vascular support to improve bone healing and prevent infections. MATERIAL AND METHODS We report our experience with this technique when applied to the lower limb in a prospective study including seven children, with a mean follow-up of 44 months. RESULTS Bone healing was achieved by one single procedure in 85.7% of the cases, usually 7 months after surgery. Six out of seven patients achieved a final and long-lasting outcome, five of them following a simple surgical history. Partial weight-bearing was post-operatively allowed at about 2 months, full weight-bearing was initiated at about 5.5 months. DISCUSSION A low complication rate was reported despite the extent of the disease and the type of the surgical procedure. Capannas combined reconstructive technique appears very efficient in the management of massive bone defects following tumour resection in childrens lower limb. LEVEL OF EVIDENCE Level IV. Retrospective therapeutic study.

Alternative à la replantation dans les amputations type doigt d’alliance stade IV : amputation basimétacarpienne d’emblée

OBJECTIVES Ray resection of the metacarpal with conservation of the proximal end is a technique of management of complete ring avulsion injuries in the emergency situation. This study is a functional evaluation of the technique in comparison to replantation. METHODS The present series includes 11 patients, average age of 35 years, predominantly manual workers, operated between October 2005 and July 2007. It consisted of two grades IVA, six grades IVB, and three grades IVC (classification of Merle-Michon). Cases were assessed according to grip and pinch strength, quantitative 400 points score and a work evaluation. RESULTS Ten patients were evaluated with an average follow-up of nine months (range: three to 19 months). There were no complications apart from four patients with phantom pain. The time to return to work was three months (range: 10-219 days). All patients were satisfied with the cosmetic appearance, however eight of them suffered from psychological problems, finding it difficult to accept a four-fingered hand. Secondary surgery was unnecessary in the majority of the patients (80%). The grip strength was measured as 30% of grip strength of the unaffected side (range: 3-70%). The result of the 400 point score was 75,94% (range: 55-99%). CONCLUSION Ray resection of the metacarpal with conservation of the proximal end is a reliable procedure. Strength is decreased but this does not stand in the way of a rapid return to previous work. However, the choice of strategy (ray resection versus microsurgical replantation) should be discussed in detail with the patient prior to selecting the appropriate option.

Vascular basis of free transfer of proximal epiphysis and diaphysis of fibula: an anatomical study

IntroductionTransfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region.Materials and methodsA total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature.ResultsThis study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck.ConclusionAccording to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.

Valeur de l’IRM dans l’évaluation du potentiel de guérison des pseudarthroses du scaphoïde traitées par greffe osseuse

Resume Objectifs Determiner si l’IRM joue un role pronostique dans le traitement par greffe osseuse de la pseudarthrose du scaphoide. Materiel et methodes Vingt et un cas de pseudarthrose du scaphoide traitee par greffe osseuse (greffon non vascularise dans 14 cas et radial vascularise dans 7 cas) ont ete prealablement explores par IRM avec des sequences frontales en FSE T2 avec Fat Sat et avec des coupes frontales et sagittales obliques dans le grand axe du scaphoide, en T1 avant et apres injection de Gadolinium. L’intensite et l’homogeneite du signal du pole proximal du scaphoide etaient analysees sur les differentes sequences par deux radiologues independants et correles aux resultats therapeutiques. Resultats Le traitement etait efficace dans 17 cas. La reproductibilite intra observateur etait de 0,92 et 0,86 ; la reproductibilite inter observateur etait de 0,88. En ponderation T1, le fragment proximal etait hyperintense dans 1 cas (succes therapeutique), en hyposignal heterogene dans 7 cas (7 reussites) et en hyposignal homogene dans 13 cas (9 reussites). En ponderation T2, le fragment proximal etait hypointense dans 4 cas (3 reussites), en hypersignal homogene dans 5 cas (4 reussites) et en hypersignal heterogene dans 12 cas (10 reussites). Apres injection de Gadolinium, le rehaussement etait homogene dans 4 cas (4 reussites), heterogene dans 8 cas (7 reussites) et absent dans 9 cas (6 reussites). Dans le groupe sans prise de contraste, 5 patients etaient traites avec un greffon radial vascularise (4 reussites) et 4 avec un greffon non vascularise (2 reussites). Conclusion L’absence de rehaussement du fragment proximal est un facteur pejoratif modere, devant orienter vers la mise en place d’un greffon vascularise.

Chronic scapholunate instability treated by scaphocapitate fusion: a midterm outcome perspective.

INTRODUCTION Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis. HYPOTHESIS Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction. MATERIAL AND METHODS A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years. RESULTS Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%. DISCUSSION These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeons armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure. LEVEL OF EVIDENCE Level 4, retrospective study.

Type II and IIIA Thumb Hypoplasia Reconstruction

Thumb hypoplasia treatment requires considering every component of the maldevelopment. Types II and IIIA hypoplasia share common features such as first web space narrowing, hypoplasia or absence of thenar muscles and metacarpophalangeal joint instability. Many surgical techniques to correct the malformation have been described. We report our surgical strategy that includes modifications of the usual technique that we found useful in reducing morbidity while optimizing the results. A diamond-shape kite flap was used to widen the first web space. Its design allowed primary closure of the donor site using a Dufourmentel flap. The ring finger flexor digitorum superficialis was transferred for opposition transfer, and the same tendon was used to stabilize the metacarpophalangeal joint on its ulnar and/or radial side depending on a uniplanar or more global instability. An omega-shaped K-wire was placed between the first and second metacarpals to maintain a wide opening of the first web space without stressing the reconstructed ulnar collateral ligament of the MCP joint. We report a clinical series of 15 patients (18 thumbs) who had this reconstructive program.

Vascularized proximal fibular epiphyseal transfer: two cases.

Vascularized proximal fibular epiphyseal transfer in children enables reconstruction of long-bone epiphyseal defect, while conserving axial growth potential. This technique was applied in two children for diaphyseal-epiphyseal reconstruction of the proximal humerus and distal radius respectively, using a graft vascularized only by the anterior tibial artery. There were no major complications during harvesting. Both cases showed transplant growth, of a mean 0.5cm/year. Joint function in the proximal humerus reconstruction was satisfactory, with functional range of motion. In the distal radius reconstruction, range of motion was almost zero; insufficient transplant growth induced radial club hand, requiring partial correction by progressive lengthening using an external fixator. In case of severe bone loss, fibular epiphyseal-diaphyseal graft vascularized only by the anterior tibial artery is a feasible attitude.