P. Liverneaux

Experience of using the bioresorbable copolyester poly(DL-lactide-ε-caprolactone) nerve conduit guide Neurolac™ for nerve repair in peripheral nerve defects: report on a series of 28 lesions.

Synthetic nerve guides are occasionally used to repair nerve defects. The aim of the present work was to analyse the results of Neurolac™ use in a series of 23 patients. We operated on 28 nerve lesions located on various sites: arm (n = 1), elbow (n = 5), forearm (n = 4), wrist (n = 2), palm (n = 5), fingers (n = 11). Defects averaged 11.03 mm and were repaired using Neurolac™. After an average of 21.9 months’ follow up (3–45 months), subjective criteria (pain, cold intolerance, Quick DASH) and objective criteria (strength, Weber and Semmes–Weinstein sensitivity tests) were compared with the contralateral side. Average pain score was 2.17/10. Cold intolerance was reported in fifteen cases. Quick DASH averaged 35.37/100. Grip strength averaged 64.62% of the contralateral side. As regards sensitivity, the difference between the two sides was 18.89 on Weber’s test, and 46.92 on Semmes–Weinstein. Defect size did not affect the outcomes. We observed eight complications the most serious being two fistulizations of the Neurolac™ device close to a joint and one neuroma. Neurolac™ presents some advantages (resorption, semi-permeability, emergency use, tenseless repair) like other synthetic guides used for nerve regeneration and its transparency constitutes an added benefit. However, some difficulty in its handling and its expensiveness represent real disadvantages. Our results are not in favour of its use in repairing hand nerve defects.

The future of robotics in hand surgery

Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.

Limb replantation with two robots: a feasibility study in a pig model.

The aim of this study is to assess the feasibility of limb replantations and transplantations by telesurgery. The material consisted in a large white pig and two surgical robots (DaVinciS® telemanipulators). The procedure consisted in a trans‐humeral cross‐section of the left thoracic limb, which was secondarily replanted. Results showed good vascular permeability, while the operators physiological tremor was suppressed. Our results seem to demonstrate that telesurgery could improve limb replantation and transplantation management, especially regarding operating gesture precision.

Kirschner wire placement in scaphoid bones using fluoroscopic navigation: a cadaver study comparing conventional techniques with navigation.

During scaphoid fixation, a pin guide is first inserted along the axis of the scaphoid, and then a cannulated screw is inserted around the pin guide. At least, the pinguide is removed. To verify the position of the pin guide, fluoroscopy is typically used, with the disadvantage of irradiation. Thus, it is impossible to visualize the pin guide in more than one view simultaneously. The goal of this study was to compare two pin guide placement techniques in scaphoid fixation: conventional (CF) vs. fluoroscopic navigation (FN).

Arthroscopic interposition arthroplasty of the trapeziometacarpal joint

PURPOSE In carpometacarpal (CMC) arthritis of the thumb, the use of interposition techniques (polylactic acid, pyrocarbon, dacron) has been increasing recently. These techniques are most often combined with open or arthroscopic complete or partial trapeziectomy. This article reports the results at one year of the arthroscopic interposition of an absorbable implant performed without trapeziectomy. METHODS Our series included 25 patients aged 60.5 years on average, presenting with osteoarthritis of the trapeziometacarpal joint that had been medically treated for 18.5 months on average. All patients were operated using 1-ulnar (U) and 1-radial (R) portals. After joint debridement, a polylactic acid implant was inserted under arthroscopic control. Outcome evaluation consisted of the assessment of pain intensity, grip strength, pinch strength, opposition, thumb abduction and Dell radiological staging. RESULTS The average follow-up was 14 months. Postoperative radiological data showed significant differences from baseline clinical data regarding all evaluated variables: 0.68 vs. 3.5 for pain, 24.76 Kg vs. 16.64 Kg for grip strength, 6.44 Kg vs. 3.64 Kg for pinch strength, 8.6 vs. 7.28 for opposition, 81.2° vs. 69.6° for thumb abduction, and 1.08 vs. 2.88 on the Dell stage. Eleven complications occurred, including a type 1 complex regional pain syndrome, one sepsis, and nine inflammatory reactions that resolved after an average of 3 weeks. CONCLUSIONS Our technique is simple, rapid, cost-effective, and does not necessitate trapeziectomy, even partial. It has the same indications as other non-radical interventions. The follow-up duration of our study was too short for long-term evaluation but short-term outcome appeared superior to that in other published series. The regional inflammatory reactions that occurred in our series were transient and probably related to implant resorption. Our promising results suggest extending the indication of arthroscopic interposition to more advanced stages of proximal joint osteoarthritis.

Distal Radius Isoelastic Resurfacing Prosthesis: A Preliminary Report.

Background Here we present a preliminary case series of unicompartmental isoelastic resurfacing prosthesis of the distal radius to treat comminuted articular fractures of osteoporotic elderly patients. Materials and Methods Our study included 12 patients, mean age 76 years, who presented with comminuted osteoporotic distal radius fracture. Because of the severity of injury and poor bone quality; osteosynthesis was not deemed to be a good option. Description of Technique The surgery was performed through a dorsal approach. The subchondral bone of the entire distal radial articular was excised and a unicompartmental prosthesis was applied. Results At an average follow-up of 32 months, the pain was 2.8/10, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) 37.4/100, grip strength in neutral 49.9%, in supination 59.0%, and in pronation 56.2% of the contralateral normal side. The wrist ranges of motion in flexion and extension were 56.1% and 79.3%, in supination and pronation 87.7% and 91.0% of the contralateral normal side. Two patients experienced a complex regional pain syndrome (CRPS) type II; these resolved spontaneously. One patient experienced distal radioulnar joint (DRUJ) stiffness, which improved after an ulna head resection. Finally, one patient required revision surgery after a secondary traumatic fracture. Radiographically; the average volar tilt was 9.8°; the average of radial inclination was 11.6°. Conclusion The concept of a unicompartmental isoelastic resurfacing prosthesis offers a promising option for the treatment of comminuted, osteoporotic distal radius articular fractures of elderly patients. Level of Evidence IV.

Fractures and dislocation of the base of the thumb metacarpal

Acute traumatic lesions of the base of the first metacarpal are frequent and their consequences can affect the opposition of the thumb. They usually occur after trauma in compression along the axis of the thumb in flexion. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries, hence why surgical treatment is usually indicated. We distinguish trapeziometacarpal dislocations, small-fragment and large-fragment Bennett’s fractures, articular three-fragment Rolando and comminutive fractures and extra-articular fractures of the base of the first metacarpal. All carry the risk of narrowing of the first web. Recent studies have described poor results with conservative treatment. Surgical techniques are varied: percutaneous surgery, open surgery and arthroscopic surgery. The techniques of osteosynthesis are various: locking plates, and direct or indirect screw fixation or pinning. The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint. Level of evidence: 4

Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot.

Surgery to transfer the axillary nerve and the nerve of the long head of the triceps presents two obstacles: 1) the access portals are not standardized and 2) the nerves are for their larger part approached through large incisions. The goal of this study was to explore the feasibility of an endoscopic microsurgical approach. The posterior aspect of a cadaver shoulder was approached through three communicating mini-incisions. The Da Vinci robot camera was installed on a central trocart, and the instrument arms on the adjacent trocarts. A gas insufflation distended the soft tissues up to the lateral axillary space. The branches of the axillary nerve and the nerve to the long head of the triceps brachii muscle were identified. The dissection of the axillary nerve trunk and its branches was easy. The posterior humeral circumflex veins and artery were dissected as well without any difficulty. Finding the nerve to the long head of the triceps brachii was found to be more challenging because of its deeper location. Robots properties allow performing conventional microsurgery: elimination of the physiologic tremor and multiplication of the movements. They also facilitate the endoscopic approach of the peripheral nerves, as seen in our results on the terminal branches of the axillary nerve and the nerve to the long head of the triceps brachii.

Robotically Assisted Microsurgery: Development of Basic Skills Course

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanipulators. This allows for the addition of optical magnification (which defines conventional microsurgery) to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in robotically asisted microsurgical training.

Digastric olecranon osteotomy: feasibility study of a new approach to the elbow

PurposeNone of the multiple posterior approaches to the elbow simultaneously satisfies the following three properties: good articular surface exposure, attention to the extensor apparatus continuity and olecranon vascularization. This study aims to describe a new approach to the elbow: digastric olecranon osteotomy.MethodsNine anatomical subjects were prepared. One-third underwent intra-articular digastric osteotomy, one-third extra-articular osteotomy and one-third a vascularization study using arteriography.ResultsDigastric olecranon osteotomy, notably intra-articular, offered excellent articular exposure. After restoration, digastric stability was excellent. Olecranon vascularization was preserved using the two variations of digastric olecranon osteotomy.ConclusionDigastric olecranon osteotomy preserves the principal vascular supply of the olecranon and the continuity of the extensor apparatus. Articular surface exposure is excellent, and the natural coaptation of the digastric enables immediate mobilization without any theoretical risk of deconstruction.