N. Gasse

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.

La rhizarthrose chez l’homme : des enjeux différents. Résultats de trois techniques chirurgicales

Basal thumb arthritis is less common in men, but the functional implication is different in this manual worker or active retired population. The objective was to analyse the results of three surgical procedure in an exclusively mens population. Twenty-eight patients (19 partial trapeziectomy with interposition of a chondrocostal autograft, seven total trapeziectomy and two prosthesis), with a mean age of 69 years old, were reviewed at a mean follow-up of 71 months. Mobility and pain were similar in the three populations. But the strength and Dash scores were better in the cartilage group. Radiologically the length of the thumb ray was greater in the cartilage group and no signs of loosening were observed in the prosthesis group. The surgery of reference in this population is the arthrodesis of the trapeziometacarpal joint. But the lack of mobility is disabling, the strength is questionable and painlessness varies due to high rates of non-union. Only one study compared four surgical procedures in an exclusively male population and total trapeziectomy seemed to give the best results. But this technique carries risk of shortening of the thumb ray. Even if the comparison is difficult, the association of partial trapeziectomy with interposition of costal cartilage graft seems to give better stability to the thumb column by preserving length as well as greater strength compared to total trapeziectomy. We advocate this procedure for basal thumb arthritis in men.

High-energy injuries of the wrist

High-energy injuries to the wrist gather complex fractures of the distal radius, radiocarpal dislocations, perilunate dislocations, and other intracarpal dislocations. Depending on the energy of the injury and the position of the wrist at the time of impact, the patient, often a young male with a high functional demand, presents one of these injuries associating fracture(s) and ligament injury. The trauma is often bilateral, with proximal lesions (elbow) very often associated with contusion or compression of the median nerve. Diagnosis is confirmed by wrist X-rays, which are sufficient to determine treatment for radiocarpal and perilunate dislocations. In cases of distal radius fractures or other intracarpal dislocations, a preoperative CT is necessary. Reduction of the dislocation and relief of neurovascular compression are performed immediately. The final treatment of each lesion (bone fixation, ligament repair) can be undertaken simultaneously or delayed, depending on the patient and the lesions. Cartilage lesions, resulting from the high-energy injury, can be estimated using arthroscopy but cannot be repaired and determine the prognosis. The surgeons objective is to restore joint congruence, which does not prevent stiffness, the main complication of these rare injuries, which the surgeon must know how to recognize and treat.

Distal radius anatomy applied to the treatment of wrist fractures by plate: a review of recent literature

Few studies on the anatomy of the radial epiphysis have been published in the past 10 years. However, with the availability of new intra- and extra-medullary implants and the recent rash of avoidable iatrogenic injuries, now is the time for a more detailed description of the metaphyseal-epiphyseal regions in the distal radius. Published studies on distal radius anatomy in recent years have focused on three aspects: distal limit and watershed line, dorsal tubercle, and wrist columns. Furthermore, a fresh look at distal radius biomechanics shows that the loads experienced by the distal radius vary greatly. This information should be taken into account during volar plating of distal radius fractures.

Adjonction d’antithrombotiques in situ en cas de replantation digitale : étude prospective préliminaire de 13 cas

Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.

Luxation dorsale ouverte métacarpophalangienne des quatre doigts longs. Réinsertion des plaques palmaires par ancres

The authors describe the case of a 53 year-old right-handed patient, who fell from a scaffolding and sustained a dorsal metacarpophalangeal dislocation of the four long fingers of his left hand. Because of the major dorsal instability after reduction, a mini anchor was placed over each metacarpal neck, to help repair the volar plate. After active rehabilitation, the patient regained satisfying articular amplitudes and was able to get back to his job and his regular sports activities.