S. Hendriks

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

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.

The utility of the fluoroscopic skyline view during volar locking plate fixation of distal radius fractures.

Background Open reduction and internal fixation (ORIF) using a volar locking plate is a common method for treating displaced distal radius fractures. There is, however, the risk of extensor tendon rupture due to protrusion of the screw tips past the dorsal cortex, which cannot always be adequately seen on a lateral fluoroscopic view. We therefore wished to compare the sensitivity of an intraoperative fluoroscopic skyline view to a lateral fluorosocopic view in detecting past pointing of these screws. Material and Methods Our series included 75 patients with an average age of 59 years who underwent volar locked plate fixation of a displaced distal radius fracture. Intraoperative anteroposterior (AP), lateral, and skyline fluoroscopic views were performed in each case. The number of screws that were seen to protrude past the dorsal cortex of the distal fracture fragment were recorded for both the lateral and skyline views. The number of screws that required exchange was also documented. Results No screws were seen to protrude past the dorsal cortical bone on the lateral fluroscopic views. 15 of 300 screws (5%) were seen to protrude past the dorsal cortex by an average of 0.8 mm (range, 0.5 to 2 mm) and were exchanged for shorter screws in 11/75 patients. Conclusion Our results demonstrate that the skyline is more sensitive than a lateral fluoroscopic view at demonstrating protrusion of the screws in the distal fracture fragment following volar locked plate fixation. Level of Evidence IV.

Interest of telemicrosurgery in peripheral nerve tumors: About a series of seven cases

Surgery of the chronic peripheral nerve lesion should not only limit recurrence after excision, but it should also limit the sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result. Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A Da Vinci S(®) robot equipped with microsurgical instruments was used for intraneural dissection. One case was performed with minimally invasive approach. At last follow-up, the pain decreased from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except for two patients, whose sensory function was improved. No recurrence was noted. Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases the accuracy of surgery. These preliminary results suggest that surgical robots could play an essential role in microsurgery.

Hand injuries due to firework devices: A series of 58 cases

Fireworks or firecrackers can cause serious accidents. They are classified from K1 to K4 according to the amount of powder they contain. In Alsace (France), a type-K1 firecracker is available on the free market and the K2 and K3 ones are prohibited. The aim of this study was to reveal the effects of measures taken in order to prevent repercussions related to hand injuries caused by fireworks. Patients who fell victim to firework incidents have been recorded since 2006, starting date of the prevention campaign. Records have been taken on the circumstances, the group of firecracker, the level of injury and the severity of the injury in four stages. Our series included 62 hands from 58 patients (average age: 25 years), including two women. Most of them sustained their injury during the night of New Years Eve. The study dealt with 21 K1, and 35 K2 or K3. We registered 29 cases of grade I, 2 grades II, 21 grades III and 9 grades IV. One patient died. The numbers of consultations, K2/K3 injuries and number of surgeries increased from 2006 to 2012. Our results show that firework-related injuries to the hand are serious, pluridigital, multistage and/or bilateral. Prevention was ineffective but should be improved and strengthened, as a total ban on fireworks is a counterproductive measure.

Arthroscopic interposition in thumb carpometacarpal osteoarthritis: A series of 26 cases.

In 2011, we reported good results after a mean follow-up of 14 months for a series of 25 patients who underwent thumb carpometacarpal osteoarthritis surgery in which a poly-L-lactic acid implant was interposed arthroscopically. The aim of this study was to evaluate the outcomes after a longer follow-up. The new series consisted of 26 patients, whose average age was 60 years, operated with arthroscopy for the interposition of an implant made of poly-L-lactic acid in 12 cases and tendon interposition in 14 cases. After an average follow-up of 20 months, the pain assessed with a visual analog scale was on average 6.61/10 before surgery and 6.03/10 after, the QuickDASH score was 56.36/100 before and 53.65/100 after, grip strength was 15.34kg before and 12.8kg after, pinch strength was 3.7kg before and 2.18kg after, Kapandji thumb opposition score was 8.96/10 before and 8.26/10 after. The radiological stage did not change. We noted one case of type 1 complex regional pain syndrome and 12 poor results, 11 of which were reoperated by trapeziectomy. Given our results and the lack of published studies with a high level of evidence, the value of isolated arthroscopy with interposition in the surgical treatment of thumb carpometacarpal osteoarthritis remains to be demonstrated.

Support for partial lesions of the flexor tendons of the fingers: A retrospective study of 36 cases

The treatment of traumatic partial injuries of the flexor tendons of the fingers is seldom published. The only published clinical series states that the therapeutic approach depends on the existence or absence of a preoperative trigger. We hypothesized that the therapeutic attitude mainly depends on the percentage of the injured cross-section. Our retrospective series included 36 partial lesions of 31 fingers in 29 patients. The average age was 42 years, there were 19 men. We noted 8 lesions in zones I, 21 in zone II and 2 in zone III. The average percentage of the injured cross-section was 35% and ranged from 10% to 90%. If the lesion was less than 50% (29 tendons), a tangential resection was performed. If the lesion exceeded 50% (seven tendons), a direct suture was performed, supplemented by a running suture. At a follow-up of 34 months, the average pain on a visual analogue scale was 0.7. The average percentage of strength compared to the contralateral side was 93%. The Quick DASH score was 6.2. The range of motion averaged 214° with extremes ranging from 90° to 260°. We observed no cases of hypertrophic callus, neither through the MRI nor through the ultrasonography. Complications such as trigger finger, pseudoblocage or rupture were not observed. Based on our results, in case of partial injury of a flexor tendon, we propose to perform a tangential resection in cross-section lesions up to 50%, and a suture for those which exceeded 50%.

Contribution of arthroscopy in case of septic appearance arthritis of the wrist: a nine cases series.

Septic arthritis of the wrist is a diagnostic and therapeutic emergency. Synovectomy and lavage by arthrotomy is often followed by stiffness. The purpose of this study was to evaluate the diagnostic and therapeutic contribution of emergency arthroscopic synovectomy with intraarticular lavage. Nine patients were operated on for wrist pathology with septic appearance. All had signs of local inflammation, three showed locoregional inflammation, three were febrile. In one patient several joints were involved. Seven patients presented with inflammatory or degenerative arthritis. All patients underwent emergency surgery using radiocarpal joint puncture, arthroscopic exploration, intraarticular lavage and synovectomy at both the radiocarpal and midcarpal joints. The results were evaluated by pain, Quick DASH, grip strength, and wrist range of motion. In three cases, joint fluid appeared clear, in three it was turbid, and in three purulent. Gram stain and culture revealed bacteria in four cases. Synovitis was radiocarpal four times, radiocarpal and midcarpal once. In one case, there was radiocarpal and midcarpal chondritis. Average pain was 5.3/10 preoperatively and 2/10 at the last clinical follow-up visit. Mean grip strength was 23.3 kg on the involved side vs. 33.5 kg on the opposite one. Mean flexion was 55° for the involved wrist vs. 68°; mean extension was 52° for the affected wrist vs. 59°. No patient was reoperated on. In all cases, there was no sign of local inflammation, regional lymphadenopathy or systemic infection at the last follow-up. One patient died of colon metastatic cancer. Another patient developed a severe Complex Regional Pain Syndrome type I (CRPS1). Our results suggest three principles of management of wrist arthritis with septic appearance: extended surgical indication, emergency operation and arthroscopic procedure.

Enlargement of the flexor pulleys by an omega plasty: A study comparing the release of one or both sides of the A2 and/or A4 pulley.

PURPOSE The omega plasty on one side of the A2 and/or A4 pulley improves the gliding of repaired flexor tendons in zone II. The purpose of this study was whether or not the enlargement of the digital channel was better after the release of one or both sides of each pulley. METHODS In fresh cadavers, the technique was to first disinsert the ulnar attachments of the A2 and A4 pulleys and then the radial insertions. An ultrasound was used to measure the large axis, the circumference, and the cross-sectional surface of each of A2 and A4 pulleys before release, after ulnar release and after radial release. RESULTS The release of the A2 pulley reduces the risk of conflict in the sutured flexor tendons in the digital channel. The release of the A4 pulley seems less effective than that of A2. The release of the two pulleys reduces the risk of conflict in one sutured zone of the flexor tendons in the digital channel. CONCLUSION In all, if there is a conflict between the flexor tendons sutured opposite A2, we recommend an omega plasty on the two sides of the pulley. If the conflict appears opposite A4, we recommend the plasty of the two sides of A4 and A2.

Evaluation of a new tourniquet for hand surgery: Comparison of 76 carpal tunnel syndrome cases operated using a Hemaclear(®) Model-F tourniquet versus a pneumatic tourniquet.

The aim of this study was to compare a forearm-specific, sterile, single-use, non-pneumatic tourniquet to a conventional pneumatic tourniquet during carpal tunnel syndrome procedures. Patients with a systolic blood pressure exceeding 160 mmHg were excluded. The study included 76 patients. In 38 patients, surgery was performed with a pneumatic tourniquet on the forearm. In the remaining 38 patients, surgery was performed with a Hemaclear(®) Model-F tourniquet. There were no significant differences between the two groups in terms of quality of the exsanguination or pain experienced by the patient. The duration of surgery was significantly faster by 30 seconds with the Hemaclear(®) tourniquet but the procedure cost was about €30 more. The forearm-specific Hemaclear(®) tourniquet has several theoretical advantages, but our clinical results do not support these advantages in terms of quality of the surgical exsanguination and pain experienced by the patient. The duration of surgery was significantly shorter, but at the price of a higher surgery cost.