Sébastien Durand

Functional Outcome of Glenohumeral Fusion in Brachial Plexus Palsy: A Report of 54 Cases

PURPOSE The restoration of shoulder function is a major issue in brachial plexus palsy. Although several tendon and nerve transfers have been described, shoulder arthrodesis remains a reliable technique in this context. This study planned to compare surgical and functional outcomes of 2 glenohumeral arthrodesis bone graft techniques: massive subacromial corticocancellous versus cancellous only grafts. METHODS We reviewed 54 patients who had shoulder arthrodesis according to 2 parameters after a mean follow-up of 37 months. The primary outcome measure was the rate of fusion according to the surgical technique. A total of 26 patients received a massive subacromial corticocancellous bone autograft, and 28 patients received only cancellous bone. The secondary outcome measure was the range of scapulothoracic motion measured by a video-assisted method according to type of neurological lesion. Brachial plexus palsy was complete in 32 cases and partial in 22 cases. All patients had recovered active elbow flexion before undergoing shoulder arthrodesis. Of the 54 patients, 48 had no postoperative immobilization. RESULTS The overall fusion rate was 76% after the first surgical procedure and 94% at last follow-up. Reoperation led to fusion in 10 cases, whereas 3 cases never fused. Pseudarthrosis rate after first surgery was 4% in the group with massive subacromial graft versus 43% in the group with cancellous bone graft. The mean range of motion was 59° in abduction (57° for complete palsy and 62° for partial palsy) with 42 cases 45° or greater. The mean range of motion was 48° in rotation (50° for complete palsy and 46° for partial palsy) with 35 cases 45° or greater. CONCLUSIONS Shoulder fusion provided active abduction greater than 45° in more than 75% of cases and active rotation greater than 45° in almost 65% of cases. Using a massive subacromial graft significantly reduced pseudarthrosis rate (P < .001). TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

PURPOSE The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. METHODS We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. RESULTS At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DISCUSSION A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. LEVEL OF EVIDENCE Level IV.

Transfer of the First Intercostal Nerve to Supra- and Infraspinatus Muscles: An Anatomical Study and Report of the First Case

We have assessed the anatomical feasibility of a transfer of the first intercostal nerve to the supra- and infraspinatus muscles and report on the first clinical application. Ten fresh cadavers were dissected for this study. Histomorphometric analysis showed the fascicular surface area of the first intercostal nerve at its origin (0.38 mm2) to be comparable to the suprascapular nerve (0.81 mm2). The first intercostal nerve is usually a pure motor nerve. Preservation of the spinal accessory nerve, lack of donor site morbidity and direct suture without nerve graft are the other advantages of this transfer. Its principal indication is in lesions of the upper brachial plexus, used in association with neurotisation of two other intercostal nerves to the anterior branch of the axillary nerve. At 21 months follow-up there was useful motor reinnervation in the first clinical case.

FDP to FDP hemi-tendon transfer – a new technique for delayed repair of the flexor digitorum profundus in zones I and II of the finger:

loads of the repaired tendons if wire suture was used. In conclusion, radiography is a useful method of investigating suture configuration changes in situ. This evaluation provides a valuable new insight into the behaviour of the most prevalent flexor tendon repair construct. A more comprehensive study comparing various suture configurations with this new method is currently being conducted in our laboratory.

Closed flexor pulley rupture of the thumb: case report and review of literature.

Closed flexor pulley rupture of the thumb is extremely rare. We report a case with this condition. The anatomic and biomechanical studies, clinical and operative finding as well as the management of the closed flexor pulley rupture of the thumb are discussed.

Triggering of the lateral slip of the extensor mechanism on a Bouchard’s node

Dear Sir, Triggering of the extensor tendon is unusual and there has been only one report of subluxation of the extensor apparatus at the level of the proximal interphalangeal joint (PIPJ) in the English language (Ikeda et al., 2000). A 75-year-old woman presented with a painful snapping sensation in the middle finger of the right hand. On examination snapping of a longitudinal cord on the radial side of the PIPJ was clearly seen, occurring at 20 of flexion, and was present on both flexing and extending the joint. There was no instability of the finger joints and the range of motion was full. The radiograph showed PIP osteoarthritis with a dorsolateral Bouchard’s node (Figure 1). On exploration under local anaesthesia a bony prominence was seen on the dorsolateral aspect of the proximal phalanx between the central slip and lateral band of the extensor mechanism, together with palmar subluxation of the radial lateral slip of the extensor and elongation of the spiral fibres (Figures 2 and 3). A Bouchard’s node is a palpable osteophyte with a constant location on the dorsolateral aspect of the PIPJ and is a marker for osteoarthritis of the joint. The anatomical location of the node is attributed to the presence of a joint capsule with an area of weakness between the collateral ligament and central slip of the extensor tendon (Alexander, 1999). In this case the formation of the node was attributed to degeneration of the bone surface at the level of the head of the proximal phalanx in the area normally responsible for guiding the lateral band of the extensor mechanism (Zancolli, 1979) together with the proximal end of the collateral ligament. As a result of this, the spiral fibres of the extensor mechanism, which are normally responsible for preventing palmar migration of the lateral bands during joint flexion, lengthened to allow such subluxation. Treatment consisted of resection of the node and preservation of the extensor mechanism, periosteal sleeve and joint ligaments (which would be important if replacement arthroplasty becomes necessary at a later date). At the same time the elongated spiral fibres were shortened using 6/0 Monocryl (Ethicon, Somerville NJ, USA) and the joint was immobilized for 3 weeks. An alternative treatment for this problem would have been that described by Ikeda et al. (2000), namely resection of the lateral band;

Locked metacarpophalangeal joint associated with PAX2 gene mutation: a case report:

had tenosynovitis due to M. xenopi infection (Coombes et al., 1996) had none of these risk factors, and both the flexor and extensor tendons of the wrist were involved. The subacute presentation, the microbiological identification and the location was highly suggestive of tuberculosis. In 33 cases of infections caused by atypical mycobacteria (Kozin and Bishop, 1994), the interval to diagnosis was around 1 year. The antibiotics helped recovery and we do not know whether this alone would have been enough without surgical debridement.

The flexor digitorum longus muscle flap for the reconstruction of soft-tissue defects in the distal third of the leg: anatomic considerations and clinical applications.

AbstractSoft-tissue defects of the distal third of the leg are common occurrences in trauma centers. The authors present the anatomic basis and their clinical experience using the flexor digitorum longus muscle flap. Ten cadaver specimens were dissected to evaluate the potential use of this flap for soft-tissue coverage in the lower third of the leg. Eleven patients underwent a soft-tissue reconstruction in the distal third of the leg with this flap. The average size of the defect covered by this flap was 11.3 cm2. This transfer flap was used in 7 cases exclusively or in combination in 4 cases. No functional deficit and good plastic result were observed in all cases. Ease of elevation and reliability has made this transfer flap the procedure of choice for small soft-tissue defects over the proximal portion of the distal tibia in our institution.

Morphogenesis of the human palma arch using three-dimensional geometric modeling

The hand goes through complex morphological modifications during embryogenesis. The goal of this study was to use geometric modeling to study the morphometric modifications of the palmar arch. Five embryos were used for the study (sizes: 15, 17, 23, 30, and 44 mm). After digitalization of histologic sections (Sony DXC‐930P 3CCD camera, Leica Qwin) and segmentation of the metacarpal cartilaginous matrices (Winsurf 4.3 software), geometric modeling and calculations were performed using MSC.Patran 2005r2 software. Correlations (r > 0.99) were found between embryo size and metacarpal volume, metacarpal surface, and the surface of the modeled palmar arch. The growth of the palmar arch is nonhomothetic. Significant reduction (P = 0.05) in the divergence of the 2nd, 3rd, 4th, and 5th metacarpals was observed. Deepening of the palmar arch is correlated with embryo size and age (r > 0.99). Geometric modeling allows 3D rendering of histologic sections and thus quantitative description of the morphogenesis. The results of this study support the hypothesis that opposition of the thumb in correlation with deepening of the palmar arch appears early in embryological development. It constitutes a specific morphological characteristic that appears very early in the human phylum. The fact that the human thumb is naturally in opposition in the resting position is a consequence of this morphogenesis. The thumbs resting position has received little attention in clinical settings and should be considered as the reference position for biomechanical analysis of the thumb column. Clin. Anat. 24:874–879, 2011.