R. Legré

Results of the Modified Brunelli Tenodesis for Treatment of Scapholunate Instability: A Retrospective Study of 19 Patients

PURPOSE Management of chronic scapholunate (SL) instability without osteoarthritis remains controversial. In order to recreate an SL interosseous linkage, some surgeons opt for a limited wrist arthrodesis, whereas others use soft tissue stabilization. The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis that used the flexor carpi radialis tendon to replicate the stabilizing ligaments of the scaphoid. METHODS Between 2001 and 2005, 19 tenodesis procedures have been performed to correct dynamic or static SL instability without osteoarthritis. On average, patients had surgery 15 months after injury. The mean follow-up was 37 months. RESULTS After surgery, 15 patients had no to mild pain with a mean visual analog scale score of 3 of 10. The average wrist motion was 50 degrees extension, 41 degrees flexion, 24 degrees radial deviation, and 29 degrees ulnar deviation (75%, 73%, 68%, and 86% of the uninvolved wrists, respectively). The grip strength was 78% of the uninvolved wrists. On radiographs, the mean static SL distance was 2.4 mm (2.8 mm before surgery). There was no widening of the SL gap compared to the immediate postoperative gap. The SL angle improved from a mean preoperative value of 61 degrees to 53 degrees immediately after surgery and rose again to 62 degrees at the time of the review. One patient developed a scapholunate advanced collapse wrist stage 2. CONCLUSIONS Ligament reconstruction using tendon grafts gave satisfactory results to correct reducible chronic SL instability without osteoarthritis. This repair technique achieved a relatively pain-free wrist, with acceptable grip strength and normal SL distance but with a loss in the arc of motion and a loss of correction of SL angle. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Nosocomial Infections with Aeromonas hydrophila from Leeches

The manner in which leeches are maintained before they are used for therapy has not been studied as a factor contributing to nosocomial infections. A 5-year retrospective survey of Aeromonas hydrophila nosocomial infections at a hospital in Marseille, France, revealed infections in 5 (4.1%) of an estimated 122 patients treated with leeches in the Hand Surgery Unit and 2 (2.4%) of an estimated 85 patients treated with leeches in other hospital units. The retrospective survey showed that the Hand Surgery Unit was the only unit that had its own aquarium for maintaining leeches; this aquarium was filled with tap water contaminated with Aeromonas species and was not regularly disinfected or cleaned. Leeches used in other units were maintained in noncarbonated water in a transport device. Use of leeches kept in aquariums that are filled with tap water and not disinfected or cleaned regularly may be linked to A. hydrophila infections.

Isolated capitate shortening osteotomy for the early stage of Kienböck disease with neutral ulnar variance.

Background: Kienböck disease is an aseptic necrosis of the lunate for which the treatment is still debated, particularly in the rare cases with neutral ulnar variance. One option is to perform a capitate shortening osteotomy associated with a capitate-hamatum arthrodesis. The aim of this study was to evaluate a simple capitate osteotomy without arthrodesis. Methods: This is a retrospective study of 11 cases. All patients had a mild form of Kienböck disease (stage I to IIIA according to the classification of Lichtman). A shortening capitate osteotomy was performed through a dorsal medial approach and fixed with staples. Results: At the final follow-up evaluation (mean, 67.4 months), the mean visual analogue scale score was 1.7 (range, 0 to 7). Based on the Nakamura score, the authors obtained six good, two fair, and three poor results. Mean strength improvement was 25 percent compared with the healthy side, and the authors observed no change in range of motion. The radiologic follow-up showed no difference in either the Stahl or the Youm index between preoperative and postoperative measurements. No complication was observed; however, in two cases, the result was evaluated as poor and a revision procedure was performed. Conclusion: This technique is a simple and reliable method with which to manage the early stages of Kienböck disease with neutral ulnar variance.

Réparations chirurgicales du nerf axillaire. Résultats à cinq ans de recul

Resume Introduction Les auteurs ont etudie retrospectivement le resultat clinique a distance des reparations du nerf axillaire chez 19 patients operes entre 1981 et 1995. Materiels et methode Sur 19 lesions du nerf axillaire, il s’agissait 14 fois d’une lesion isolee, 5 fois d’une lesion associee soit a une lesion du nerf radial, soit a une lesion du nerf scapulaire superieur. Le mecanisme du traumatisme correspondait dans 14 cas a un etirement en traction du membre superieur. La serie comportait 3 fractures de la ceinture scapulaire et 2 luxations antero-internes de l’epaule. L’intervention chirurgicale a ete faite en moyenne 9 mois apres le traumatisme initial par une double voie d’abord anterieure et posterieure. La lesion siegeait au niveau de l’espace quadrilatere de Velpeau et l’intervention a consiste en une greffe nerveuse dans 17 cas, et en une neurolyse dans 2 cas. Resultats Les resultats ont ete satisfaisants dans 10 cas sur 14 pour les lesions isolees du nerf axillaire avec 2 tres bons, 8 bons et 2 resultats moyens selon le score de Constant. Les neurolyses et les atteintes combinees du nerf axillaire et du nerf scapulaire superieur dans la serie ont conduit a des echecs. Discussion Les resultats sont encourageants avec un indice de satisfaction correct malgre une fatigabilite accrue de l’epaule operee, par rapport a l’epaule controlaterale. En l’absence d’IRM l’electromyogramme reste l’examen de reference pour determiner la periode operatoire, avant que n’apparaisse une amyotrophie trop severe et pour eviter d’intervenir sur un nerf en voie de recuperation infraclinique.

Arthrodèse d'épaule avec fibula vascularisée après résection tumorale de l'extrémité supérieure de l'humérus

PURPOSE OF THE STUDY Resection of malignant tumors of the proximal humerus often requires dissection of the rotator cuffs and the deltoid muscle. There is no consensus on the ideal method for shoulder reconstruction. We report the functional outcome in a homogeneous series of eight patients treated by arthrodesis using a vascularized free fibular flap. MATERIAL AND METHODS Eight patients were included in this study. All had an aggressive tumor of the upper humerus. Tumor resection was associated with a rotator cuff and deltoid muscle resection in all patients. All patients then underwent shoulder arthrodesis using a free vascularized fibular flap fixed with a plate. Clinical and radiological evaluation was available for six patients at mean 28 months. The Musculoskeletal Tumor Society function score was used to assess overall function of the upper limb. The cosmetic outcome and radiographic bone healing as well as hypertrophy of the fibular graft were noted. RESULTS Active abduction and active flexion were 82 degrees on average. All patients could bring their hand to the mouth. Circumduction was possible but limited in amplitude. The mean function score was 26.5/30 with an excellent functional outcome in all patients. The cosmetic outcome was considered poor by all patients. Radiographically, bone healing was achieved at last follow-up in all patients but there was one case of failed fusion between the fibular graft and the scapula which required secondary iliac grafting. Mean fibular graft hypertrophy was 32.8% at last follow-up. DISCUSSION AND CONCLUSION Two reconstruction methods have been described for patients who require tumor resection of the upper humerus: reconstruction with preservation of glenohumeral joint function and shoulder arthrodesis. Many techniques have been described for each method. It is however difficult to compare the different series reported in the literature because rotator cuff and deltoid muscle resection was not systematically performed and reconstruction methods varied between patients. An analysis of the literature shows that preservation of motion of the scapular glenoid joint can give good functional results when the rotator cuff and deltoid muscle can be preserved. If they cannot, results favor shoulder arthrodesis which provides the patient with very satisfactory upper limb function. Use of a vascularized fibular flap has provided very good arthrodesis results. The patient must however be informed of the probable poor final cosmetic result.Purpose of the study Resection of malignant tumors of the proximal humerus often requires dissection of the rotator cuffs and the deltoid muscle. There is no consensus on the ideal method for shoulder reconstruction. We report the functional outcome in a homogeneous series of eight patients treated by arthrodesis using a vascularized free fibular flap. Material and methods Eight patients were included in this study. All had an aggressive tumor of the upper humerus. Tumor resection was associated with a rotator cuff and deltoid muscle resection in all patients. All patients then underwent shoulder arthrodesis using a free vascularized fibular flap fixed with a plate. Clinical and radiological evaluation was available for six patients at mean 28 months. The Musculoskeletal Tumor Society function score was used to assess overall function of the upper limb. The cosmetic outcome and radiographic bone healing as well as hypertrophy of the fibular graft were noted. Results Active abduction and active flexion were 82q on average. All patients could bring their hand to the mouth. Circumduction was possible but limited in amplitude. The mean function score was 26.5/30 with an excellent functional outcome in all patients. The cosmetic outcome was considered poor by all patients. Radiographically, bone healing was achieved at last follow-up in all patients but there was one case of failed fusion between the fibular graft and the scapula which required secondary iliac grafting. Mean fibular graft hypertrophy was 32.8% at last follow-up. Discussion and conclusion Two reconstruction methods have been described for patients who require tumor resection of the upper humerus: reconstruction with preservation of glenohumeral joint function and shoulder arthrodesis. Many techniques have been described for each method. It is however difficult to compare the different series reported in the literature because rotator cuff and deltoid muscle resection was not systematically performed and reconstruction methods varied between patients. An analysis of the literature shows that preservation of motion of the scapular glenoid joint can give good functional results when the rotator cuff and deltoid muscle can be preserved. If they cannot, results favor shoulder arthrodesis which provides the patient with very satisfactory upper limb function. Use of a vascularized fibular flap has provided very good arthrodesis results. The patient must however be informed of the probable poor final cosmetic result.

Résultats des sutures nerveuses au poignet chez l'enfant

Resume Introduction Les traumatismes des nerfs peripheriques constituent des lesions severes du membre superieur. Le pronostic de recuperation demeure incertain malgre la microchirurgie. Il est classiquement admis que les resultats sont meilleurs chez l’enfant que chez l’adulte. Nous avons voulu confirmer cette notion par des criteres objectifs de recuperation et faire la part des choses entre regeneration axonale peripherique et capacites d’adaptation propre a l’enfant. En d’autres termes, le nerf repousse-t-il mieux chez l’enfant ? Materiel et methode Les resultats cliniques de 25 sutures nerveuses au niveau du poignet, chez des enfants de moins de 15 ans, ont ete analyses avec un recul minimal de douze mois. La revision a ete clinique et electromyographique. Les chiffres recueillis ont ete compares a ceux rencontres dans la litterature pour l’adulte. Resultats Sur le plan clinique, la fonction globale de la main est toujours satisfaisante. Les resultats sensitifs sont le plus souvent excellents (S4 ou S3+ dans 23 cas / 25). La valeur moyenne du testing musculaire se situe entre M2 et M3. D’un point de vue EMG, les valeurs recueillies ne sont que rarement le reflet du resultat fonctionnel. Les traces moteurs sont le plus souvent pauvres, compenses par un important phenomene de reinnervation collaterale. Discussion Les mauvais resultats de la chirurgie nerveuse peripherique ne sont pas le seul fait d’une faible reinnervation. Dellon et Mackinnon ont montre qu’ils etaient egalement dus a l’incapacite pour les centres nerveux d’integrer des informations sensorielles dont le profil est modifie. La repousse nerveuse ne serait pas seulement imparfaite en quantite mais egalement en qualite. L’enfant, doue de capacites cerebrales d’adaptation superieures a l’adulte, beneficie probablement d’une meilleure acquisition corticale et donc d’une meilleure utilisation de ces messages alteres. L’analyse des resultats cliniques et electromyographiques oriente, chez l’enfant egalement, vers une repousse nerveuse partielle. Nous pensons que les resultats fonctionnels sont surtout le fait d’une adaptation d’origine centrale.

Maladie de Madelung : ostéotomie isolée de l'ulna

Objectives Madelung deformity is defined as a partial closure of the medial half of the distal radial growth plate, with anatomical consequences (wrist deformity), and functional impairment (decrease range of motion, loss of grip strength, and wrist pain). We report a new surgical procedure including a shortening of the ulna combined with slight anterior flexion osteotomy aiming to correct the radio-ulnar dislocation and to improve the range of forearm rotation, without correcting the global deformity.

Note techniqueMaladie de Madelung : ostéotomie isolée de l'ulnaMadelung deformity: isolated ulnar wedge osteotomy

Objectives Madelung deformity is defined as a partial closure of the medial half of the distal radial growth plate, with anatomical consequences (wrist deformity), and functional impairment (decrease range of motion, loss of grip strength, and wrist pain). We report a new surgical procedure including a shortening of the ulna combined with slight anterior flexion osteotomy aiming to correct the radio-ulnar dislocation and to improve the range of forearm rotation, without correcting the global deformity.

Surgery for trapeziometacarpal osteoarthritis

Trapeziometacarpal (TMC) osteoarthritis is a common, disabling condition that mostly affects women. The demand for surgical treatment is growing and the patients are becoming younger, adding to the challenge. Surgery can only be proposed after failure of well-conducted conservative treatment and requires a complete X-ray assessment. In the early stages, conservative surgery measures can be used to stabilize the joint or realign it in cases of dysplasia, but in most cases, patients are seen with more advanced arthritis and joint replacement must be considered. The ideal arthroplasty technique has yet to be defined but nevertheless, the chosen technique must be well-suited to the patients condition. Although many studies have been published on this topic, they do not help us define the treatment indications. Prospective studies focusing on the patient rather than evaluating a certain surgical technique are needed. Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications. Arthrodesis, interposition or arthroplasty are also viable therapeutic options. The patient must be sufficiently informed to be able to contribute to choosing the indication.

Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps

Background When microsurgical transfers are required in posttraumatic lower limb reconstruction, surgeons must choose among many types of free flaps. Historically, surgeons have advocated muscular flaps for coverage of open lower extremity wounds, but fasciocutaneous free flaps are now often used with good results. This study aimed to compare the functional and aesthetic outcome of reconstruction by free muscular latissimus dorsi (LD) flap and free fasciocutaneous anterolateral thigh (ALT) flap used for soft tissue coverage of distal lower extremity open fractures. Methods We performed a single‐center, retrospective study of subjects with distal lower limb open fractures treated with LD flaps or ALT flaps between 2008 and 2014. Patients with limited follow‐up or incomplete data were excluded from the analysis. Donor and recipient sites, early complications and long‐term outcomes (functional and aesthetic) were studied and compared according to the type of flap. Results A total of 47 patients were included: 27 patients in the LD flap group and 20 patients in the ALT flap group. No significant difference was found regarding early and late complications and long‐term functional outcomes (bone healing, infectious bone complications, flap healing). As for aesthetic outcome and donor‐site morbidity, reconstruction using the ALT free flap had significantly better results (p < 0.05). Conclusions In posttraumatic lower limb injury, either LD or ALT free flaps can be used for wound coverage with comparable long‐term functional outcomes. The ALT flap provides better cosmetic results than LD.